Social Epistemology Vol. 22, No. 4, October–December 2008, pp. 325–331 INTRODUCTION The Rhetoric of Research Methodology Jason Grossman and Joan Leach HowTaylorTSEP_A_356904.sgm10.1080/02691720802567365Social0269-1728Original2008224000000October-DecemberJoanLeachj.leach@uq.edu.au Epistemologyand& Article Francis (print)/1464-5297Francis Ltd 2008Can (online) We Describe the Dominant Rhetoric that is Evidence-Based Medicine? Evidence-Based Medicine (EBM) is the dominant rhetoric in health research. So effec- tive is this dominant rhetoric that if you work outside EBM or question its practices your position is unlikely to be taken seriously. This is doubly so if you question EBM from within a complimentary or alternative medicine framework. You are likely to be seen as a complainer; as not as rigorous as you should be; as operating from the epistemic Paleolithic. This issue of Social Epistemology explores what EBM is, what it should be, and why it has become the dominant rhetoric and everything else has become a counter-rhetorical force. So What is EBM? Most importantly, Evidence-Based Medicine (EBM) is not just medicine based on evidence. To make this clear, consider what it would look like if, counterfactually, EBM was medicine based on evidence. For one thing, it would then be restricted to medi- cine; but while EBM is, perhaps, restricted to the health disciplines, its scope runs way Downloaded By: [University of Maastricht] At: 19:51 4 January 2009 beyond the territory claimed by the gatekeepers of what is medical. In that sense, the scope of EBM is broader than the uninitiated might expect. But more importantly (and therefore receiving far more attention in this issue of Social Epistemology), there is a sense in which the scope of EBM is narrower than its name suggests. This is in the dimension of methodology. Does anything based on evidence count as evidence- based? Absolutely not. This claim, that something based on evidence can fail to be evidence-based in the terms set by EBM, might seem to be a bold one. It requires two types of support: on one side of the equation, it requires us to know what we mean by “evidence”; on the other side it requires proper documentation of the claim that much that is evidence (once we know what that means) is verboten according to EBM. ISSN 0269–1728 (print)/ISSN 1464–5297 (online) © 2008 Taylor & Francis DOI: 10.1080/02691720802567365 326 J. Grossman and J. Leach So what is evidence? That might seem to be a crucial question. But we think that in order to see the poverty of EBM, it is not necessary to answer it very fully. We take the following (actual) exchange as our guide: The scene is a university seminar room circa 2001. A seminar on Lacan is in progress. Audience member: “There’s no evidence for that”. Speaker: “You have too narrow a view of evidence”. Audience member: “I don’t have any view of evidence. Make some noises designed to get me to believe it”. The lesson we take home from this exchange (which we take to be a win for the opening player) is that any piece of language (or in principle any other semiosis) which supports an assertion is evidence for that assertion. And although we cannot argue this here in detail, it seems obvious that convincing noises (perhaps with some caveats about rationality or social norms or some such) are what make for good evidence. EBM Takes a Very Different View As we will see in more detail in the papers in this issue (especially those by Derkatch, La Caze, and Grossman), what counts as good evidence in EBM, and even in many cases what counts as evidence at all, depends on a particular view (a very particular view) of The Scientific Method. This Scientific Method (even capitals cannot do justice to the singularity and respect it is granted) is ossified in various competing yet highly similar sets of prescriptions enunciated by the various experts in EBM. As La Caze puts it: experimental evidence from clinical studies is distinguished according to methodology (La Caze, this issue, 356; author’s emphasis) If you run with EBM’s methodological prescriptions, you are providing evidence. If you don’t, you are not … no matter that you might be supporting a major conclusion with empirical data, a knock-down argument, a mathematical proof, and the Tablets of Moses. Note that there are several contentious ingredients here: the very idea that there is a single Scientific Method; the ossification of that method into a set of low-level rules; a Downloaded By: [University of Maastricht] At: 19:51 4 January 2009 whole variety of problems with what exactly those rules are (see especially Dowe and Grossman); and the exclusion of anything else. Among the types of evidence which do not count as evidence for EBM, the types most often disputed are various kinds of “observational” studies, a term of art used to denote and (to some extent) denigrate any empirical study which is not a randomised controlled trial. The papers by Derkatch, La Caze, and Grossman discuss problems with this partic- ular exclusion. But another exclusion often goes unnoticed, although very clear in both the literature on EBM and the literature of EBM. This is the exclusion of “basic” science, which in the EBM lexicon means anything which is not a direct examination of the effects of a proposed intervention on humans. Most prominent in this category of basic science is laboratory research, including such varied disciplines as organic chemistry, molecular genetics, biophysics, physiology, pharmacology, histology and so on. As Adam La Caze explains: Social Epistemology 327 These sciences are primarily focused on developing a theoretical basis for how the body works (physiology), how drugs interact with physiological processes in the body (pharma- cology) and the physiological abnormalities involved in disease (pathophysiology). (La Caze, this issue, 355) Even randomised controlled trials performed on (non-human) animals count as basic science according to EBM, and therefore cannot count as good quality evidence. La Caze is one of the few theorists who are exploring this strange categorisation of evidence and the resulting cognitive dissonance in a scientific community which takes basic research as its bedrock and yet denies that it gives us good evidence. In his paper in this issue, he considers an obvious move to solve this problem, namely restricting the scope of EBM so that basic research would be considered to give bad evidence for some medical purposes but good evidence for other purposes. He shows that although this move has merit it does not succeed in making sense of the evidence categorisations of EBM. So What Exactly is EBM? Now we know what EBM is not. We also know, in the abstract, that EBM is effectively defined by a set of rules and, of course, social practices around those rules. And we know a little about the rules. But what exactly are the rules? Why haven’t we just listed them for you? The attempt to answer these questions at the level of detail required to understand the rules and social practices of EBM constitutes a whole field of research in itself, one which is pursued in part in the papers by Lipworth et al., La Caze, and Grossman. While there is some research talking about medical practice using EBM (especially RCTs), and we hope there will be more, what we are doing in this edition of Social Epistemology is looking more abstractly at what questions such sociological research should attempt to answer. A question which needs to be raised immediately is: who is best placed to comment on what EBM is and should be? And who is even qualified to do so? It is an enquiry in which doctors have so far been the presumed experts. Indeed, it is implicit in much EBM literature that only the leaders of the movement, a surprisingly small number of Downloaded By: [University of Maastricht] At: 19:51 4 January 2009 clinical epidemiologists, are fully qualified to define EBM. Lipworth et al. discuss this concentration of power in terms of exceptionalism, the idea being that it is primarily the claim that EBM is special which has resulted in the protection of its central doctrines by its leaders: it is conceivable that EBM exceptionalism has resulted in a similar concentration of power in the hands of those who accept and have expertise in the principles and practices of EBM, and has marginalized those who do not. (Lipworth et al., this issue, 427–8) Lipworth et al. warn of the potential dangers of exceptionalism. Were EBM treated as less exceptional, they say, it might be more able to incorporate “novel” ideas (although this might come at some cost): non-exceptionalism allows practitioners to draw on insights from elsewhere rather than “re-inventing the wheel”. … it could be very useful to draw on the rich insights and 328 J. Grossman and J. Leach practical strategies of those who, throughout the history of medicine, have reflected on the role of evidence in medical practice. And it could be very useful to recognize the similarities between the evidence-generating and evidence-applying principles of EBM and those of law, engineering and politics. (Lipworth et al., this issue, 428) Even theoretical statisticians are relatively disenfranchised by EBM. For the importance of this point, see the papers by Dowe and Grossman. The question of the definition of EBM, taking into account social practices as well as rules, is one which the medical disciplines do not yet know how to take seriously. So far, the story of EBM is internalist history, history told by the victor, even though the victory isn’t yet clear.