There is a vast literature on evidence-based practice in education. What function does evidence have in practical deliberations toward decisions about what to do? Most writers on EBP seem to think of evidence largely as quantitative data, serving as a foundation from which practice could and should be directly derived. In this paper I argue that we are better served by according a different and more indirect function to evidence in practical reasoning. To establish (...) this claim I employ Toulmin’s model of argumentation. On this model the evidence-as-foundation view amounts to evidence as data/grounds. The model also offers a different function for evidence, as backing of the warrant, and I argue in this paper that this is a more adequate understanding of the function of evidence in practical reasoning. (shrink)

The present study has two goals: to explore elementary students’ understanding of evidence and the ways they deploy it to construct arguments, and to examine whether eliciting their concept of evidence during argumentation improves students’ evidence-based reasoning. Individual semi-structured interviews were conducted with 4th and 6th graders in a public school in Mexico. We found significant differences between groups regarding the concept of evidence, with better performance in the older group. A positive correlation between (...) the concept of evidence and the quality of evidence-based reasoning was found. Also, three performance profiles were observed after eliciting the concept of evidence when grade was excluded as a factor. Results suggest that the concept of evidence plays an essential role in developing argumentative competence in pre-adolescence. (shrink)

This paper explores the reasons why the notion of 'evidence-based' practice has gained prominence in educational research. The ascendancy of 'evidence-based' practice is attributed to a crisis of legitimation in educational research. The paper offers a critical exegesis of a systematic review conducted under the auspices of the Effective Practice and Organisation of Care (EPOC) subgroup of the Cochrane Collaboration.

Evidence based medicine (EBM) is under critical debate, and person centered healthcare (PCH) has been proposed as an improvement. But is PCH offered as a supplement or as a replacement of EBM? Prima facie PCH only concerns the practice of medicine, while the contended features of EBM also include methods and medical model. I here argue that there are good philosophical reasons to see PCH as a radical alternative to the existing medical paradigm of EBM, since the two (...) seem committed to conflicting ontologies. This paper aims to make explicit some of the most fundamental assumptions that motivate EBM and PCH, respectively, in order to show that the choice between them ultimately comes down to ontological preference. While EBM has a solid foundation in positivism, or what I here call Humeanism, PCH is more consistent with causal dispositionalism. I conclude that if there is a paradigmatic revolution on the way in medicine, it is first of all one of ontology. (shrink)

The philosophy of evidence-based medicine -- What is EBM? -- What is good evidence for a clinical decision? -- Ruling out plausible rival hypotheses and confounding factors : a method -- Resolving the paradox of effectiveness : when do observational studies offer the same degree of evidential support as randomized trials? -- Questioning double blinding as a universal methodological virtue of clinical trials : resolving the Philip's paradox -- Placebo controls : problematic and misleading baseline measures of (...) effectiveness -- Questioning the methodological superiority of "placebo" over "active" controlled trials -- Examining the paradox that traditional roles for mechanistic reasoning and expert -- Judgment have been up-ended by EBM -- A qualified defence of the EBM stance on mechanistic reasoning -- Knowledge that versus knowledge how : situating the EBM position on expert clinical judgment -- Moving EBM forward. (shrink)

Proponents of evidence-based medicine have argued convincingly for applying this scientific method to medicine. However, the current methodological framework of the EBM movement has recently been called into question, especially in epidemiology and the philosophy of science. The debate has focused on whether the methodology of randomized controlled trials provides the best evidence available. This paper attempts to shift the focus of the debate by arguing that clinical reasoning involves a patchwork of evidential approaches and that (...) the emphasis on evidence hierarchies of methodology fails to lend credence to the common practice of corroboration in medicine. I argue that the strength of evidence lies in the evidence itself, and not the methodology used to obtain that evidence. Ultimately, when it comes to evaluating the effectiveness of medical interventions, it is the evidence obtained from the methodology rather than the methodology that should establish the strength of the evidence. (shrink)

Evidence-Based Medicine (EBM) is defined as the conscious, and judicious use of current best evidence in making decisions about the care of individual patients. The greater the level of evidence the greater the grade of recommendation. This pioneering explicit concept of EBM is embedded in a particular view of medical practice namely the singular nature of the patient-physician relation and the commitment of the latter towards a specific goal: the treatment and the well being of his (...) or her client. Nevertheless, in many European countries as well as the United States, this integration of the best evidence from systematic research with clinical expertise and patient values appears to be re-interpreted in light of the scarcity of healthcare resources. The purpose of this paper is double. First, to claim that from an ethical perspective EBM should be a guideline to clinical practice; and second, that in specific circumstances EBM might be a useful tool in macro-allocation of healthcare resources. Methodologically the author follows Norman Daniels' theory of democratic accountability to justify this assumption. That is, choices in healthcare must be accountable by democratic procedures. This perspective of distributive justice is responsible for the scope and limits of healthcare services. It follows that particular entitlements to healthcare — namely expensive innovative treatments and medicines —may be fairly restricted as long as this decision is socially and democratically accountable and imposed by financial restrictions of the system. In conclusion, the implementation of EBM, as long as it limits the access to drugs and treatments of unproven scientific results is in accordance with this perspective. The use of EBM is regarded as an instrument to facilitate the access of all citizens to a reasonable level of healthcare and to promote the efficiency of the system. (shrink)

Background The increase in empirical methods of research in bioethics over the last two decades is typically perceived as a welcomed broadening of the discipline, with increased integration of social and life scientists into the field and ethics consultants into the clinical setting, however it also represents a loss of confidence in the typical normative and analytic methods of bioethics. Discussion The recent incipiency of "Evidence-Based Ethics" attests to this phenomenon and should be rejected as a solution to (...) the current ambivalence toward the normative resolution of moral problems in a pluralistic society. While "evidence-based" is typically read in medicine and other life and social sciences as the empirically-adequate standard of reasonable practice and a means for increasing certainty, I propose that the evidence-based movement in fact gains consensus by displacing normative discourse with aggregate or statistically-derived empirical evidence as the "bottom line". Therefore, along with wavering on the fact/value distinction, evidence-based ethics threatens bioethics' normative mandate. The appeal of the evidence-based approach is that it offers a means of negotiating the demands of moral pluralism. Rather than appealing to explicit values that are likely not shared by all, "the evidence" is proposed to adjudicate between competing claims. Quantified measures are notably more "neutral" and democratic than liberal markers like "species normal functioning". Yet the positivist notion that claims stand or fall in light of the evidence is untenable; furthermore, the legacy of positivism entails the quieting of empirically non-verifiable considerations like moral claims and judgments. As a result, evidence-based ethics proposes to operate with the implicit normativity that accompanies the production and presentation of all biomedical and scientific facts unchecked. Summary The "empirical turn" in bioethics signals a need for reconsideration of the methods used for moral evaluation and resolution, however the options should not include obscuring normative content by seemingly neutral technical measure. (shrink)

Evidence-based medicine frequently uses statistical hypothesis testing. In this paradigm, data can only disconfirm a research hypothesis’ competitors: One tests the negation of a statistical hypothesis that is supposed to correspond to the research hypothesis. In practice, these hypotheses are often misaligned. For instance, directional research hypotheses are often paired with non-directional statistical hypotheses. Prima facie, one cannot gain proper evidence for one’s research hypothesis employing a misaligned statistical hypothesis. This paper sheds lights on the nature of (...) and the reasons for such misalignments and it provides a thorough analysis of whether they pose a threat to evidence-based medicine. The upshots are that the misalignments are often hidden for clinicians and that although some cases of misalignments can be partially counterbalanced, the overall threat is non-negligible. The counterbalances either lead to methodological inadequacy, loss of statistical power, or involve a lack of information that could be crucial for decision making. This result casts doubt on various findings of medical studies in addition to issues associated with under-powered studies or the replication crisis. (shrink)

As a recent special report in the Hastings Center Report demonstrates, many bioethicists are rethinking the way we regulate both biomedical research and clinical practice, as well as the sharp boundary that the field has assumed can and should exist between them. Such a rethinking is long overdue. There is surely a meaningful normative distinction between activities whose expected risk‐benefit profile is and is not “reasonable” for participants (to echo the language in the Common Rule—the core set of human research (...) guidelines found in many federal regulations). But neither the research‐practice distinction nor the criteria underlying it—the intention of the actor, whether the activity is “systematic,” and whether its results are “generalizable”—closely track good and bad outcomes for research participants and patients or justify either the bureaucratic, paternalistic licensing system that governs human subjects research or the comparatively lax governance of medical practice. The specious distinction between research and practice is especially ripe for dismantling in light of the embarrassing fact that evidence‐based medicine remains more aspiration than reality. (shrink)

Johnson -Laird has argued that spatial reasoning is based on the construction and manipulation of mental models in memory. The present article addresses the question of whether reasoning about time relations is constrained by the same factors as reasoning about spatial relations. An experiment is reported that explored the similarities and the differences in the performance of subjects in comparable spatial and temporal reasoning tasks. The results indicated that, in both the temporal and the spatial (...) content domains, the data were in agreement with the view that subjects solved problems by constructing models in memory rather than with a logical rule conceptualisation of reasoning. An analysis of the premise-reading times on the basis of premise-linking order provided support for an on-line process of mental models construction, and offered an explanation for the finding that spatial problems that did require an inference of transitivity were easier than problems that did not. No essential differences in processing and performance were observed across the two content domains, although in the time domain the correctness data were in agreement with both the mental models theory and the logical rules view. The results are discussed with respect to the mental models theory and the structural characteristics of the problems. (shrink)

The oil crisis, risk and evidence‐based practice Evidence‐based practice has risen to prominence over the last 20 years. Different professions have taken it up in different ways and for different purposes. It has been seen as holding both threats and advantages to professionalising endeavours and professional identity. It has engendered controversy but some criticisms of it have been unconvincing. It is possible to account for its rise as a response to tightening financial constraints on state spending (...) in the west, as a sign of a culture increasingly concerned with risk, distrust of professionals and experts, as well as a way for professionals themselves to maintain control over their activity in the face of growing managerialism. This paper reviews the literature of some of the movement's proponents as well as criticism from various professional groups. It concludes that more useful than either arguing for or against it, is to understand the policy background and sociological reasons for its emergence and spread. (shrink)

The clinical decision is supposed to be based on evidence. In fact, what counts as evidence is far from being established. Some definition of "proof" is needed to distinguish between scientific medicine and charlatanism. My thesis is that unfortunately a clear-cut boundary between evidence and lack of evidence cannot be found, for several reasons that I summarise in the paper. Evidence in medicine very often has fuzzy boundaries, and dichotomising fuzziness and uncertainty can have (...) serious consequences. Physicians and patients should accept the irreducible fuzziness of many of the concepts they use when dealing with health and disease. (shrink)

Evidence-based medicine (EBM) has long deemphasized mechanistic reasoning and pathophysiological rationale in assessing the effectiveness of interventions. The EBM+ movement has challenged this stance, arguing that evidence of mechanisms and comparative studies should both be seen as necessary and complementary. Advocates of EBM+ provide a combination of theoretical arguments and examples of mechanistic reasoning in medical research. However, EBM+ proponents have not provided recent examples of how downplaying mechanistic reasoning resulted in worse medical results (...) than would have occurred otherwise. Such examples are necessary to make the case that EBM+ responds to a problem in clinical practice that urgently demands a solution. In light of this, we examine the failed rollout of efavirenz as a first-line HIV treatment in Zimbabwe as evidence of the importance of mechanistic reasoning in improving clinical practice and public health policy decisions. We suggest that this case is analogous to examples commonly given to support EBM. (shrink)

Traditionally, surgical practice has been experiential and based on the contemporary understanding of basic mechanisms of disease. It was both a science and an art and depended to far too great an extent on the individualism and self belief of its main exponents. “Evidence based medicine” emerged in the 1980s and a new gospel of “Rules of Evidence” was introduced. There is no doubt that the net effect of EBM has been beneficial, but over reliance on (...) randomised controlled trials and the lack of generalisability of scientific evidence to individual patients has perhaps led to less enthusiasm for its tenets among surgeons. There are valid and spurious reasons for this that are discussed. The situation is improving but inevitable tensions remain between the surgeon committed to the individual patient here and now, and the clinical researcher whose focus is the benefit of future patients in the larger community. (shrink)

Gilbert et al. have raised important questions about the empirical grounding of neuroethical analyses of the apparent phenomenon of Deep Brain Stimulation ‘causing’ personality changes. In this paper, we consider how to make neuroethical claims appropriately calibrated to existing evidence, and the role that philosophical neuroethics has to play in this enterprise of ‘evidence-based neuroethics’. In the first half of the paper, we begin by highlighting the challenges we face in investigating changes to PIAAAS following DBS, explaining (...) how different trial designs may be of different degrees of utility, depending on how changes to PIAAAS following DBS are manifested. In particular, we suggest that the trial designs Gilbert et al. call for may not be able to tell us whether or not DBS directly causes changes to personality. However, we suggest that this is not the most significant question about this phenomenon; the most significant question is whether these changes should matter morally, however they are caused. We go on to suggest that neuroethical analyses of novel neuro-interventions should be carried out in accordance with the levels of evidence hierarchy outlined by the Centre for Evidence-Based Medicine, and explain different ways in which neuroethical analyses of changes to PIAAAS can be evidence-based on this framework. In the second half of the paper, we explain how philosophical neuroethics can play an important role in contributing to mechanism-based reasoning about potential effects on PIAAAS following DBS, a form of evidence that is also incorporated into the CEBM levels of evidence hierarchy. (shrink)

The evidence-based turn in education reveals renewed consensus on empiricism and shared trust in science as if it were the allegedly value-free basis for decision-making: good, justifiable governance should be a non-discretional corollary of scientific knowledge. The article focuses on some risks implied in pursuing the de-moralization of educational decision-making, namely the realistic, the reductionist, and the perspective fallacies, as well as the minimization of individual responsibility in favor of the third-person perspective implied in following protocols and guidelines. (...) In the discussion I address some possible reasons for the appeal of the evidence-based turn despite these risks: the contemporary pressure for “accountability” and the need to justify social policies and practices with consensual criteria. In the conclusion, I claim that educational decision-making should deploy rather than conceal its moral bases despite their being potentially highly divisive. Consequently, I make a case for “moral accountability”: making publicly inspectable what evidence-based education tries to conceal, i.e. the unavoidable value-ladeness of educational policies and practices. (shrink)

Evidence based-policy (EBP) is a popular research paradigm in the applied social sciences and within government agencies. Informally, EBP represents an explicit commitment to applying scientific methods to public affairs, in contrast to ideologically-driven or merely intuitive “common-sense” approaches to public policy. More specifically, the EBP paradigm places great weight on the results of experimental research designs, especially randomised controlled trials (RCTs), and systematic literature reviews that place evidential weight on experimental results. One hope is that such research (...) designs and approaches to analysing the scientific literature are sufficiently robust that they can settle what really ‘works’ in public policy. Can EBP succeed in displacing reliance on domain-specific expertise? On our account, this is seldom, if ever, the case. The key reason for this is that underlying this approach is generally an appeal to argument by induction, which always requires further assumptions to underwrite its validity, and if not induction, some other argument form that also requires assumptions that are very often not validated for the case at hand. (shrink)

The idea that prescribing physicians should be guided by the most reliable scientific evidence seems obvious, but the actual methodology of evidence-based medicine was only introduced in the early 1990s by an international group of clinicians and researchers led by Gordon Guyatt. Since then it has provided a new paradigm for the scientific foundation of medicine and has influenced other disciplines outside of medicine, for example, evidence-based psychotherapy, science and government. The novel concept of (...) class='Hi'>evidence-based medicine is based on hierarchies of evidence from opinions of respected authorities, mechanistic reasoning, and reports of expert committees at the bottom to... (shrink)

When evidence-based policymaking is so often mired in disagreement and controversy, how can we know if the process is meeting its stated goals? We develop a novel mathematical model to study disagreements about adequate knowledge utilization, like those regarding wild horse culling, shark drumlines and facemask policies during pandemics. We find that, when stakeholders disagree, it is frequently impossible to tell whether any party is at fault. We demonstrate the need for a distinctive kind of transparency in (...) class='Hi'>evidence-based policymaking, which we call transparency of reasoning. Such transparency is critical to the success of the evidence-based policy movement, as without it, we will be unable to tell whether in any instance a policy was in fact based on evidence. (shrink)

Evidence-based medicine (EBM) has thus far failed to adequately account for the appropriate incorporation of other potential warrants for medical decision making into clinical practice. In particular, EBM has struggled with the value and integration of other kinds of medical knowledge, such as those derived from clinical experience or based on pathophysiologic rationale. The general priority given to empirical evidence derived from clinical research in all EBM approaches is not epistemically tenable. A casuistic alternative to EBM (...) approaches recognizes that five distinct topics, 1) empirical evidence, 2) experiential evidence, 3) pathophysiologic rationale, 4) patient goals and values, and 5) system features are potentially relevant to any clinical decision. No single topic has a general priority over any other and the relative importance of a topic will depend upon the circumstances of the particular case. The skilled clinician must weigh these potentially conflicting evidentiary and non-evidentiary warrants for action, employing both practical and theoretical reasoning, in order to arrive at the best choice for an individual patient. (shrink)

According to current hierarchies of evidence for EBM, evidence of correlation (e.g., from RCTs) is always more important than evidence of mechanisms when evaluating and establishing causal claims. We argue that evidence of mechanisms needs to be treated alongside evidence of correlation. This is for three reasons. First, correlation is always a fallible indicator of causation, subject in particular to the problem of confounding; evidence of mechanisms can in some cases be more important than (...) evidence of correlation when assessing a causal claim. Second, evidence of mechanisms is often required in order to obtain evidence of correlation (for example, in order to set up and evaluate RCTs). Third, evidence of mechanisms is often required in order to generalise and apply causal claims. While the EBM movement has been enormously successful in making explicit and critically examining one aspect of our evidential practice, i.e., evidence of correlation, we wish to extend this line of work to make explicit and critically examine a second aspect of our evidential practices: evidence of mechanisms. (shrink)

Thirty years after the rise of the evidence-based medicine (EBM) movement, formal training in philosophy remains poorly represented among medical students and their educators. In this paper, I argue that EBM’s reception in this context has resulted in a privileging of empiricism over rationalism in clinical reasoning with unintended consequences for medical practice. After a limited review of the history of medical epistemology, I argue that a solution to this problem can be found in the method of (...) the 2nd-century Roman physician Galen, who brought empiricism and rationalism together in a synthesis anticipating the scientific method. Next, I review several of the problems that have been identified as resulting from a staunch commitment to empiricism in medical practice. Finally, I conclude that greater epistemological awareness in the medical community would precipitate a Galenic shift toward a more epistemically balanced, scientific approach to clinical research. (shrink)

We live in an age of evidence-based healthcare, where the concept of evidence has been avidly and often uncritically embraced as a symbol of legitimacy, truth, and justice. By letting the evidence dictate healthcare decision making from the bedside to the policy level, the normative claims that inform decision making appear to be negotiated fairly—without subjectivity, prejudice, or bias. Thus, the term ‘‘evidence-based’’ is typically read in the health sciences as the empirically adequate standard (...) of reasonable practice and a means for increasing certainty. Supporters believe that evidence-based medicine (EBM) can introduce rational order to the deliberative processes of healthcare decision making. It is perhaps puzzling, then, to come across critical perspectives (typically arising from the humanities and the more theory-driven social sciences) raising concerns about a seeming technogovernance being introduced by this deferral to the evidence where power interests can be obfuscated by way of technical resolve. The critics holding this minority view argue that technological solutions to problems of knowledge and practice cannot replace medicine’s normative content. Against EBM’s democratic leanings toward transparency and accountability, medical criteria alone cannot decide valueladen ethically charged decisions. This paper attempts to explain and evaluate this important debate in the philosophy of medicine, focusing specifically on the dispute over 'evidence-based women's health'. (shrink)

Reasoners compare problems to prior cases to draw conclusions about a problem and guide decision making. All Case-Based Reasoning (CBR) employs some methods for generalizing from cases to support indexing and relevance assessment and evidences two basic inference methods: constraining search by tracing a solution from a past case or evaluating a case by comparing it to past cases. Across domains and tasks, however, humans reason with cases in subtly different ways evidencing different mixes of and mechanisms for (...) these components.In recent CBR research in Artificial Intelligence (AI), five paradigmatic approaches have emerged: statistically-oriented, model-based, planning/design-oriented, exemplar-based, and adversarial or precedent-based. The paradigms differ in the assumptions they make about domain models, the extent to which they support symbolic case comparison, and the kinds of inferences for which they employ cases. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Evidence-Based Medicine and EvaluativismTim Thornton (bio)KeywordsPhilosophy, psychiatry, values, causalThe rise of evidence-based medicine (EBM) in psychiatry has brought, in its train, a concentration on the validity of psychiatric taxonomy to augment the previous focus on reliability (in the medical sense of inter-subject agreement). This is not surprising. If EBM is to be a trustworthy guide to future events, such as patient recovery, it must be (...) based on projectible predicates (Goodman 1983). Not all the predicates that apparently fit past observations would produce true predictions for the future. Furthermore, there is reason to think that employing projectible predicates goes a long way to satisfy the (widespread if contested) aim of being based on a nomological science (Papineau 1986). Thus, the successful implementation of EBM within psychiatry requires the successful articulation of a valid psychiatric taxonomy.This connection helps to explain why fears about the application of EBM to psychiatry often turn on fears about the application of the criteriological model of diagnosis to individuals. In her commentary in this issue, Gloria Ayob has examined some of the arguments concerning the application of EBM to individuals. In this brief commentary, I examine a different potential source of disquiet focused on the underlying nature of psychiatric taxonomy.Dimensions for Psychiatric TaxonomyIn their recent paper, Peter Zachar and Kenneth Kendler suggest a number of different dimensions according to which rival conceptions of psychiatric taxonomy can be mapped. These include (1) causalism–descriptivism, (2) essentialism– nominalism, (3) objectivism–evaluativism, (4) internalism–externalism, (5) entities–agents, and (6) categories–continua (2007, 557). At the heart of the objectivism-evaluativism dimension is the question:Is deciding whether or not something is a psychiatric disorder a simple factual matterY (objectivism), or does it inevitably involve a value-laden judgment (evaluativism)?(Zachar and Kendler 2007, 558)Objectivists argue that the concept of disorder is a simple or plain factual matter by contrast with an evaluation. The apparently evaluative connotations of disorder, they argue, can either be reduced to, or explained away in, more basic terms, which are not themselves essentially evaluative. Thus, for example, the attempt to explain disorder in statistical terms is a form of objectivism. The more plausible attempt to explain disorder through the idea of a biological or proper function is also usually presented as a form of objectivism. (The most famous proponent of a biological approach, however, Jerome Wakefield, adds to an objectivist-aspiring core an explicit value in the form of harm [End Page 175] [Wakefield 1999].) Whether or not it can be successful as a form of objectivism, in addition to whether an analysis in biological terms is possible, depends on whether the account of function can fully discharge any initial evaluative or normative assumptions.There seems to be good evidence that current psychiatric taxonomy, at least, contains values. John Sadler, for example, makes a powerful case for this in his substantial work Values and Psychiatric Diagnosis (2005). Sadler, furthermore, addresses in some detail a further set of questions concerning the kinds and nature of the values involved. I outline just one further question about the nature of values involved.Zachar and Kendler contrast the presence of values with objectivism. Objectivity has at least two relevant senses reflecting contrasts with two senses of subjectivity. It—objectivity—might mean requiring no special subject for the conception and framing of relevant judgments. (This mirrors primary, by contrast with secondary qualities, and Williams' idea of an absolute conception [Williams 1978]). Or, it might mean disciplining and providing a contrast between correctness and incorrectness, or truth and falsity, for the relevant judgments. This contrasts with subjective whimsy.Although it seems relatively straight forward that the conception and framing of value judgments requires that subjects have a particular kind of mind, that still leaves open the other issue. Are value judgments disciplined by anything or does the "truth" of a value judgment collapse back into its being sincerely made?Evaluativism in Psychiatric Taxonomy and EBMThis question relates to the application of EBM to psychiatry in this way. On a disciplined account, psychiatric taxonomy can aim to get right the mixture or, better, the compound of simple facts and values... (shrink)

In this paper, I use the evidential function of chances and counterfactuals to develop accounts of these relations. Chances are objective worldly probabilities that allow us to reason from the state of a system at one time to the state of a system at another time. Counterfactuals are used to reason about what evidence we would have in hypothetical cases—and so, I’ll argue, are evaluated by considering ‘branch points’ where the counterfactual antecedent had a reasonable chance of coming about. (...) An upshot is that counterfactuals play a distinct role from causal relations—and it was a mistake to look for a single set of probabilities that would determine both how we should reason about the world (counterfactuals) and how states of the world depend on others under conditions of manipulation (causal relations). These evidential accounts do better than nearby statistical-mechanical accounts in identifying the function of distinctly modal relations and justifying why we reason about the world in modal terms. They also do better at identifying the source of the temporal asymmetries in these relations—they are due to a probability gradient of the universe, rather than to a special initial state. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Evidence-Based Medicine and EvaluativismTim Thornton (bio)KeywordsPhilosophy, psychiatry, values, causalThe rise of evidence-based medicine (EBM) in psychiatry has brought, in its train, a concentration on the validity of psychiatric taxonomy to augment the previous focus on reliability (in the medical sense of inter-subject agreement). This is not surprising. If EBM is to be a trustworthy guide to future events, such as patient recovery, it must be (...) based on projectible predicates (Goodman 1983). Not all the predicates that apparently fit past observations would produce true predictions for the future. Furthermore, there is reason to think that employing projectible predicates goes a long way to satisfy the (widespread if contested) aim of being based on a nomological science (Papineau 1986). Thus, the successful implementation of EBM within psychiatry requires the successful articulation of a valid psychiatric taxonomy.This connection helps to explain why fears about the application of EBM to psychiatry often turn on fears about the application of the criteriological model of diagnosis to individuals. In her commentary in this issue, Gloria Ayob has examined some of the arguments concerning the application of EBM to individuals. In this brief commentary, I examine a different potential source of disquiet focused on the underlying nature of psychiatric taxonomy.Dimensions for Psychiatric TaxonomyIn their recent paper, Peter Zachar and Kenneth Kendler suggest a number of different dimensions according to which rival conceptions of psychiatric taxonomy can be mapped. These include (1) causalism–descriptivism, (2) essentialism– nominalism, (3) objectivism–evaluativism, (4) internalism–externalism, (5) entities–agents, and (6) categories–continua (2007, 557). At the heart of the objectivism-evaluativism dimension is the question:Is deciding whether or not something is a psychiatric disorder a simple factual matterY (objectivism), or does it inevitably involve a value-laden judgment (evaluativism)?(Zachar and Kendler 2007, 558)Objectivists argue that the concept of disorder is a simple or plain factual matter by contrast with an evaluation. The apparently evaluative connotations of disorder, they argue, can either be reduced to, or explained away in, more basic terms, which are not themselves essentially evaluative. Thus, for example, the attempt to explain disorder in statistical terms is a form of objectivism. The more plausible attempt to explain disorder through the idea of a biological or proper function is also usually presented as a form of objectivism. (The most famous proponent of a biological approach, however, Jerome Wakefield, adds to an objectivist-aspiring core an explicit value in the form of harm [End Page 175] [Wakefield 1999].) Whether or not it can be successful as a form of objectivism, in addition to whether an analysis in biological terms is possible, depends on whether the account of function can fully discharge any initial evaluative or normative assumptions.There seems to be good evidence that current psychiatric taxonomy, at least, contains values. John Sadler, for example, makes a powerful case for this in his substantial work Values and Psychiatric Diagnosis (2005). Sadler, furthermore, addresses in some detail a further set of questions concerning the kinds and nature of the values involved. I outline just one further question about the nature of values involved.Zachar and Kendler contrast the presence of values with objectivism. Objectivity has at least two relevant senses reflecting contrasts with two senses of subjectivity. It—objectivity—might mean requiring no special subject for the conception and framing of relevant judgments. (This mirrors primary, by contrast with secondary qualities, and Williams' idea of an absolute conception [Williams 1978]). Or, it might mean disciplining and providing a contrast between correctness and incorrectness, or truth and falsity, for the relevant judgments. This contrasts with subjective whimsy.Although it seems relatively straight forward that the conception and framing of value judgments requires that subjects have a particular kind of mind, that still leaves open the other issue. Are value judgments disciplined by anything or does the "truth" of a value judgment collapse back into its being sincerely made?Evaluativism in Psychiatric Taxonomy and EBMThis question relates to the application of EBM to psychiatry in this way. On a disciplined account, psychiatric taxonomy can aim to get right the mixture or, better, the compound of simple facts and values... (shrink)

Consider any choice that affects some social policy. A decision that considers evidence will, at its heart, contain some kind of explicit or implicit “because” statement: “We are doing X because the evidence says Y.” But can evidence ever truly speak for itself, in the sense of being reducible to objective utterances that are either correct or in need of correction? Before answering, consider what you'd prefer. Would you rather receive evidence that was free of any (...) value judgments imposed by human actors, that was laden with value judgments that you agree with, or laden with value judgments that you disagree with? The central assertion of this essay is that, throughout policy analysis but especially in assessments of the costs and benefits of regulating versus encouraging new technologies (cost‐benefit analysis, or CBA), the first possibility above is a mirage, and the second and third are self‐contradictory. Instead, we are overwhelmingly confronted with a fourth possibility: we receive evidence that appears to be (or is deliberately touted as) value neutral but is suffused with hidden value judgments.In the second part of this essay, entitled “A Guided Tour through Inevitable Value Judgments,” I identify in a systematic way approximately sixty‐five value judgments that are routinely (in some cases, invariably) made in CBA, but that are kept hidden. For each judgment, I discuss its genesis as it is most commonly invoked in CBA, explain how it is hidden in plain sight, and offer one or more value judgments that could be made instead of or in addition to the conventional one. The alternative judgments highlight the width of the spectrum of reasonable conclusions an analyst could reach merely by substituting other judgments for the ones currently embedded.Bringing hidden value judgments to light is doubly valuable. First, it allows discussion to ensue on a level playing field; instead of conclusory statements about what the evidence says, transparency permits statements taking the form of “when channeled through these value judgments, the evidence says this.” Perhaps more importantly, transparency about value judgments permits participants in the discussions to offer interpretations of evidence contingent on there being different value judgments chosen at one or more points in the analysis, interpretations that may suggest that alternative course(s) of action are preferable to the one being championed. (shrink)

Despite its phenomenal success since its inception in the early nineteen-nineties, the evidence-based medicine movement has not succeeded in shaking off an epistemological critique derived from the experiential or tacit dimensions of clinical reasoning about particular individuals. This critique claims that the evidence-based medicine model does not take account of tacit knowing as developed by the philosopher Michael Polanyi. However, the epistemology of evidence-based medicine is premised on the elimination of the tacit dimension (...) from clinical judgment. This is demonstrated through analyzing the dichotomy between clinical and statistical intuition in evidence-based medicine’s epistemology of clinical reasoning. I argue that clinical epidemiology presents a more nuanced epistemological model for the application of statistical epidemiology to the clinical context. Polanyi’s theory of tacit knowing is compatible with the model of clinical reasoning associated with clinical epidemiology, but not evidence-based medicine. (shrink)

Despite the innovation that evidence-based medicine (henceforth EBM) represents for biomedical sciences today, we argue that its strict evidential hierarchies do not faithfully represent the epistemic and practical reality of the evidence that should be used to make appropriate clinical decisions. We defend that it is necessary to make modifications to the methodology and models of clinical decision-making proposed by EBM and make them more sensitive to the use of different types of evidence and reasoning. (...) Since various types of evidence and reasoning, and medical expertise still play an irreducible role in clinical decision-making, rather than continuing with their strict hierarchies, we argue that those who subscribe to the EBM paradigm should discuss in much greater detail different types of evidence and reasoning. Admitting and advocating the role of other types of evidence and reasoning in clinical decision-making will also be necessary to introduce other types of inference and evaluation, as this generates conclusions that do not rely solely on induction or deduction. Both clinical judgment and the clinical eye play a prominent role in this context, particularly in diagnosis, as uncertainty inherently influences the process. If we hit the nail on the head, effective EBM practice requires other types of reasoning beyond biostatistical reasoning. With this in mind, we characterize clinical judgment based on abductive inference. (shrink)

Even though the evidence‐based medicine movement (EBM) labels mechanisms a low quality form of evidence, consideration of the mechanisms on which medicine relies, and the distinct roles that mechanisms might play in clinical practice, offers a number of insights into EBM itself. In this paper, I examine the connections between EBM and mechanisms from several angles. I diagnose what went wrong in two examples where mechanistic reasoning failed to generate accurate predictions for how a dysfunctional mechanism (...) would respond to intervention. I then use these examples to explain why we should expect this kind of mechanistic reasoning to fail in systematic ways, by situating these failures in terms of evolved complexity of the causal system(s) in question. I argue that there is still a different role in which mechanisms continue to figure as evidence in EBM: namely, in guiding the application of population‐level recommendations to individual patients. Thus, even though the evidence‐based movement rejects one role in which mechanistic reasoning serves as evidence, there are other evidentiary roles for mechanistic reasoning. This renders plausible the claims of some critics of evidencebased medicine who point to the ineliminable role of clinical experience. Clearly specifying the ways in which mechanisms and mechanistic reasoning can be involved in clinical practice frames the discussion about EBM and clinical experience in more fruitful terms. (shrink)

Questions of how we claim to know the things that we know and whose claims to knowledge are treated as authoritative are inescapable in reaching legal judgments. I want to illustrate this generalization by referring to a pair of hypothetical self-defense cases that, I argue, require fact finders to judge both how “accurately” each defendant understood the situation in which he found himself and how accurately policymakers can assess the consequences of alternative legal rules.The first case I will deal with (...) is one in which the defendant shoots and kills her sleeping husband. The husband had physically abused her over a long period. While the defendant will of course acknowledge that she was in no immediate danger at the moment she killed the man, her preliminary claim is that she needed to act self-defensively at that moment for fear that she subsequently would be incapable of defending herself against life-threatening attacks that she was convinced would inevitably be made.The second case is one in which a white defendant shoots and kills a black teenager who has confronted him on the subway, in a situation in which the teenager’s “threats” were ambiguous. The shooting victim had brandished no weapon and made no physical contact with the defendant, but he had “asked” the defendant for money and, in the defendant’s mind, displayed a generally threatening demeanor. I will presuppose that this defendant—unlike Bernhard Goetz, the defendant in the notorious New York subway vigilante case on which I partly base this hypothetical model—overtly acknowledges that the race of the victim played a substantial role in his assessment of the danger of the situation. Mark Kelman, professor of law at Stanford University, is the author of A Guide to Critical Legal Studies as well as a number of articles on law and economics, taxation, criminal law, and legal theory. (shrink)

In the international context of a progress toward more inclusive educational systems and practices, the role of Special Education teachers is being transformed. From an inclusive perspective, these professionals increasingly support students and their teachers in the mainstream classroom, avoiding segregation. However, Special Education teachers often struggle to reach and support all students with special needs and their teachers to provide quality inclusive education. For this reason, more research is still needed on in-service training strategies for the inclusion of students (...) with special needs that effectively translate into evidence-based school practices that improve the education of all students. This article analyses the impact of two evidence-based dialogic training programs of Special Education teachers working in mainstream schools carried out in Mexico during the 2018–2019 school year. Through in-depth interviews with participants, it was identified how, after the training, teachers increasingly grounded their actions on scientific evidence and promoted interactive learning environments that improved the educational inclusion of their students with special needs. This training also became the venue to make evidence-based educational actions available to other students without special needs, improving the quality of education provided to all students. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Do People Defy Generalizations?Examining the Case Against Evidence-Based Medicine in PsychiatryGloria Ayob (bio)KeywordsPhilosophy, psychiatry, action, contentEvidence-based medicine (EBM) in psychiatry presupposes that it is possible to track the causal efficacy of treatments for psychopathological conditions using scientific methods. One central aim of EBM is to ascertain the causally efficacious component of the treatment of a given condition. This is done by collecting data from randomized control (...) trials, where this data are of groups rather than of individuals (Bolton, 2008).EBM is felt by many to have significant limitations when applied in the field of psychiatric medicine, and these limitations are thought to arise owing to a particular fact about psychiatry, namely that the subject of psychiatry is the human person. For brevity, I will refer to this broad claim as the Unsuitability Intuition (UI), which can be stated as follows:The UI is the intuition that EBM is somehow unsuitable for dealing with people.The aims of this paper are twofold. First, I try to pinpoint the source(s) of anxiety about EBM, and therein to clarify the exact sense(s) in which EBM might be said to be unsuitable or problematic. Second, I evaluate the validity of these concerns, focusing on two broad interrelated questions: (1) Is it actually something about human persons that creates trouble for EBM in psychiatry, and if so, what is the nature of this trouble?; and (2) What assumptions about EBM are made such that EBM is problematic in light of the fact that the subject of psychiatry is the human person?As an empirical point, EBM in psychiatry is applied to two methods of treatment: psychotropic drugs, and more recently, cognitive–behavioral therapies. Each of these throws up slightly different issues in light of the two questions just identified. To accommodate relevant differences, I structure this paper as follows. Bearing in mind that the overall aim of the paper is to scrutinize the intuition that EBM is somehow unsuitable for dealing with people, I begin by exploring one common suggestion as to what underpins this intuition: The problem we are confronted with, in applying EBM to people, is the problem of applying generalizations to particular instances (Wifstad 2008). To anticipate, I argue that this worry concerns a problem that, in fact, applies to the scientific method in general. That is, it is not a [End Page 167] problem arising specifically from the fact that the subject of psychiatry is the human person. So if this is the worry about EBM, then as it stands, it does not satisfactorily explain the intuition that EBM is somehow unsuitable for dealing with people.Against this, the UI theorist might defend his intuition by attempting to specify the reasons why persons, unlike physical material, present a special challenge to the scientific method presupposed by EBM. One way of doing this is to point out that the determinants of human behavior cannot be captured by generalizations (and in particular, by causal generalizations). There are two ways of worrying about EBM here: On the first, the problem of EBM in psychiatry is a pragmatic worry that arises in view of the complexity of the determinants of human behavior and the limited capacity for observation. If this is the worry, though, it can be overcome to a greater or lesser extent within psychiatric practice. The second worry consists in the thought that humans pose a constitutive problem for EBM in psychiatry. However, I argue that this worry turns out to rest on assumptions about human behavior that are not unproblematic in themselves. Thus, UI is underpinned either by a pragmatic worry that can be overcome to some extent, or else it is underpinned by certain assumptions that are problematic, if not altogether wrong. This means that UI cannot be founded on a constitutive point about persons—at least, it does not seem to be, if it arises from a concern about applying generalizations to individual human beings.But there is a very different type of worry that might underpin UI, one that does not issue from considerations about the relation between the general and the particular. UI theorists could be worried about specific... (shrink)

Objective: To examine the role of explainability in machine learning for healthcare (MLHC), and its necessity and significance with respect to effective and ethical MLHC application. Study Design and Setting: This commentary engages with the growing and dynamic corpus of literature on the use of MLHC and artificial intelligence (AI) in medicine, which provide the context for a focused narrative review of arguments presented in favour of and opposition to explainability in MLHC. Results: We find that concerns regarding explainability are (...) not limited to MLHC, but rather extend to numerous well-validated treatment interventions as well as to human clinical judgment itself. We examine the role of evidence-based medicine in evaluating unexplainable treatments and technologies, and highlight the analogy between the concept of explainability in MLHC and the related concept of mechanistic reasoning in evidence-based medicine. Conclusion: Ultimately, we conclude that the value of explainability in MLHC is not intrinsic, but is instead instrumental to achieving greater imperatives such as performance and trust. We caution against the uncompromising pursuit of explainability, and advocate instead for the development of robust empirical methods to successfully evaluate increasingly inexplicable algorithmic systems. (shrink)

The evolution of medical reasoning is deeply intertwined with philosophical thought, beginning with Aristotle’s foundational work in deductive logic. Aristotle’s principles significantly influenced early medical practice, shaping the works of Galen and Avicenna, who made empirical observations that expanded clinical knowledge. During the Enlightenment, both inductive reasoning, as advocated by Francis Bacon, and deductive methods, as stressed by René Descartes, significantly advanced medical reasoning. These approaches proved insufficient when it came to handling uncertainty and variability in medical (...) outcomes. Nineteenth-century figures like William Osler advanced a probabilistic understanding of medicine. Karl Popper’s 20th-century hypothetico-deductive method, which introduced the concept of falsifiability and transformed scientific inquiry into a rigorous process of hypothesis testing, is a fundamental aspect of evidence-based medicine (EBM). EBM emerged as the dominant paradigm, combining empirical research, clinical expertise, and statistical inference to guide medical decisions. Looking forward, Bayesian reasoning offers a further refinement in medical reasoning. By incorporating prior knowledge and continuously updating probabilities with new evidence, Bayesianism addresses the limitations of frequentist methods and offers a more dynamic and adaptable framework for clinical decision making. As medical reasoning evolves, understanding this philosophical lineage is essential to navigating the future of patient care, where evidence must be both rigorously tested and individually tailored. (shrink)

Meta‐analysis: the glass eye of evidence‐based practice?Meta‐analysis was developed as a technique for combining the results of many different quantitative studies: it is often used to produce quantitative estimates of causal relations and/or association between variables. Meta‐analysis is sometimes regarded as a central component of evidence‐based practice. We draw attention to an incompatibility in the epistemology and methods of reasoning in quantitative meta‐analysis and the epistemology and reasoning implicit in expert practice. We argue that (...) this may be because the common perception of meta‐analysis appeals to truth as correspondence; we suggest that rejecting the naïve realism that underpins truth as correspondence allows meta‐analysis to be understood in terms of truth as coherence. We can then develop an account of meta‐analysis that does not depend upon reduction to a mathematical procedure but is an attempt to maximise coherence in beliefs about what works that is consistent with clinical reasoning in expert practice. (shrink)

In the philosophy of mind, neuroscience, and psychology, the causal relationship between phenomenal consciousness, mentation, and brain states has always been a matter of debate. On the one hand, material monism posits consciousness and mind as pure brain epiphenomena. One of its most stringent lines of reasoning relies on a ‘loss-of-function lesion premise,’ according to which, since brain lesions and neurochemical modifications lead to cognitive impairment and/or altered states of consciousness, there is no reason to doubt the mind-brain identity. (...) On the other hand, dualism or idealism (in one form or another) regard consciousness and mind as something other than the sole product of cerebral activity pointing at the ineffable, undefinable, and seemingly unphysical nature of our subjective qualitative experiences and its related mental dimension. Here, several neuroscientific findings are reviewed that question the idea that posits phenomenal experience as an emergent property of brain activity, and argue that the premise of material monism is based on a logical correlation-causation fallacy. While these (mostly ignored) findings, if considered separately from each other, could, in principle, be recast into a physicalist paradigm, once viewed from an integral perspective, they substantiate equally well an ontology that posits mind and consciousness as a primal phenomenon. (shrink)

The interaction between evidence-based medicineand doctors' duty of care to patients iscomplex. One the one hand, there is surely anobligation to take account of the bestavailable evidence when offering health care topatients. On the other hand, it is equallyimportant to be aware of important shortcomingsin the processes and practices ofevidence-based medicine. There are tensionsbetween the population focus of evidence-basedmedicine and the duties that doctors have toindividual patients. Implementingevidence-based medicine may have unpredictableconsequences upon the overall (...) quality of healthcare. Patients may have a range of reasons forpreferring one form of treatment over another,not all of which are captured by currentformulations of evidence. This paper examinesthese issues, using relevant examples fromevidence-based medicine. (shrink)

A contemporary serious lack of scientific knowledge by the general public and many decision-makers is now quite perceptible, both globally and in Portugal. Living in a science-driven technological world filled with scientific illiteracy is dangerous and a path toward disaster. Recent years brought a fairly strong global movement promoting the so-called “alternative therapy” that also affected Portugal. I propose an evidence-based ethics reflection and argumentation, both encompassing the global and the specific Portuguese reality. I debate the specific arguments (...) used in favour of alternative therapies, demonstrating the inherent fallacies of thought, deliberate manipulation of words and concepts, and the dire consequences for global and local health politics by following this line of biased reasoning. (shrink)

The purpose of this paper is to improve on the logical and measure-theoretic foundations for the notion of probability in the law of evidence, which were given in my contributions Åqvist [ (1990) Logical analysis of epistemic modality: an explication of the Bolding–Ekelöf degrees of evidential strength. In: Klami HT (ed) Rätt och Sanning (Law and Truth. A symposium on legal proof-theory in Uppsala May 1989). Iustus Förlag, Uppsala, pp 43–54; (1992) Towards a logical theory of legal evidence: (...) semantic analysis of the Bolding–Ekelöf degrees of evidential strength. In: Martino AA (ed) Expert systems in law. Elsevier Science Publishers BV, Amsterdam, North-Holland, pp 67–86]. The present approach agrees with the one adopted in those contributions in taking its main task to be that of providing a semantic analysis, or explication, of the so called Bolding–Ekelöf degrees of evidential strength (“proof-strength”) as applied to the establishment of matters of fact in law-courts. However, it differs from the one advocated in our earlier work on the subject in explicitly appealing to what is known as “Pro-et-Contra Argumentation”, after the famous Norwegian philosopher Arne Naess. It tries to bring out the logical form of that interesting kind of reasoning, at least in the context of the law of evidence. The formal techniques used here will be seen to be largely inspired by the important work done by Patrick Suppes, notably Suppes [(1957) Introduction to logic. van Nostrand, Princeton and (1972) Finite equal-interval measurement structures. Theoria 38:45–63]. (shrink)

Religion refers to two excuses for the deliberately abandoning of prayers: sleep and forgetting. However, according to some scholars, some other reasons may also allow the deliberately abandoning of prayers. The most important support of these scholars is that the Messenger of Allah performed some prayers outside their own time during the al-Khandaq. However, there is a serious obstacle in front of this approach: The fear prayer. The aim of the article is to reveal the relationship between this application of (...) the Prophet and the fear prayer and investigates whether it is a general rule to leave a prayer due to the fear of war or the enemy. The importance of this issue stems from the fact that the practice in this battle is comparable. If this is accepted as a general rule, the framework of the issues that may cause a prayer to be left can be expanded. Excuses that can be considered force majeure and legitimate in terms of daily life can be added to the unconscious states of harmony and forgetting. Therefore, the article mentions a much smaller dimension of this broad framework, rather than the general aspects of the issue, such as the deliberately abandoning of prayers, whether it is possible or not, and its proofs. In this context, it can be said that it is of great importance to determine the historical sequence between this battle and the prayer of fear. The article comes to a conclusion through the determination of this relationship, which has clues in various hadith, history, and commentary books. (shrink)

This article draws upon issues within the debate on evidence-based policy raised in the academic literature and in recent government documentation. The article assesses the extent to and ways in which policy development and implementation on adult basic skills (literacy and numeracy) within the National Probation Service (NPS) are evidencebased. It is argued that the albeit limited amount of empirical evidence on adult basic skills, methodological insights gained through empirical research, and expert opinion have shaped the NPS (...) basic skills strategy. To enhance policy implementation, findings from the NPS pathfinder evaluation have been disseminated to practitioners. It is aimed to build research evidence on basic skills in the NPS in a cumulative way and to use findings to shape policy development on an ongoing basis. The lack of a systematic review on adult basic skills is used to explore reasons for gaps in evidence-based policy on basic skills in the NPS. The article concludes that a range of types of evidence has shaped policy development on basic skills in the NPS. (shrink)

Increasing philosophical attention is being directed to the rapidly growing discipline of evidence-based medicine. Philosophical discussions of EBM, however, remain narrowly focused on randomization, mechanisms, and the sociology of EBM. Other aspects of EBM have been all but ignored, including the nature of clinical reasoning and the question of whether it can be standardized; the application of EBM principles to the logic, value, and ethics of diagnosis and prognosis; evidence synthesis ; and the nature and ethics (...) of placebo controls. Philosophical analysis in each of these areas has the potential to enhance the discussion of EBM methodology and practice. (shrink)