Evidence-based medicine: requiescat in pace? A commentary on Djulbegovic, B., Guyatt, G. H. & Ashcroft, R. E. (2009) Cancer Control, 16, 158-168.

Over the last 15 academic volumes of publication of the Journal of Evaluation in Clinical Practice (JECP), the Editor, with an extensive number of colleagues internationally, has called continuously for the advocates of evidence-based medicine (EBM) to answer their critics in an open, intellectually rigorous and collegiate manner [1–14]. Now, some of the leading protagonists of EBM – Benjamin Djulbegovic, Gordon Guyatt and Richard Ashcroft – have risen, finally, to that challenge [15]. Or have they? In recalling one phrase: ‘all comes to ye who waits’, I am reminded immediately of another: ‘half a loaf is better than none’. Why? Because in finally addressing many of the substantive criticisms of the theoretical foundations and practical applicability of EBM, the authors present at best an incomplete thesis and in the process miss a valuable opportunity to contribute to the intellectual resolution of the ongoing arguments, something which is their duty to engage in as scholars [16]. The JECP has long considered EBM and its advocates to be both unscientific and antiscientific. Unscientific because they have based their thesis on assumptions rather than on a proven hypothesis that EBM can improve both the process and outcome of clinical intervention, relying preferentially on seductive rhetoric and misleading nomenclature in the advancement of their attempts to secure for EBM a position of absolute reference for competency in medical practice [17,18]. Antiscientific because EBM has promoted its own top-down approach to the identification of knowledge for practice based on aberrant methodological premises known as ‘rules of evidence’ and has consistently and determinedly avoided an active participation in the democratic, consensus building, ‘bottom-up’ processes of science. Within these contexts, EBM has typically demonstrated one of the most hubristic and authoritarian stances seen in Medicine in recent centuries and one of the most magisterial disdains of criticism that have even been seen in clinical science [18,19]. The immediately controversial nature of the EBM thesis, with its talk of the ‘radical restructuring of medical knowledge’, ‘paradigm shifts’ [20] and its attempts to distinguish ‘active, evidence-based clinicians’ from ‘passive, opinion-based spectators of clinical practice’ [21] (see Miles and Loughlin [13] and Wyer and da Silva [22] for a useful recent overview and review, respectively), resulted in a visceral reaction of the international medical community that has, over time, forced one concession from EBM after another, so that the serial reconstitutions of EBM have left the foundational claims of EBM in conceptual and methodological ruins. During the last few years, there have been a number of insipid and sporadic attempts by the EBM community to concede the presence of defects in the concept and methods of their thesis. These have ranged from the difficulties even EBM advocates have experienced in implementing EBM practices [23] and the difficulties EBM has had in integrating patients’ values and preferences with ‘the evidence’ [24], factors which resulted in the inevitable acknowledgement by EBM leaders that ‘EBM has limitations and further innovation is required to resolve some of these’ (italicization mine) [23,25–27]. Add to these observations, the vacuity of theses such as those advanced by Jenicek [28–30] and we see a shocking picture of how, following the synthesis of the brand name ‘EBM’, a systematic attempt was made to revolutionize the whole nature of medical practice in the absence of a soundly worked out theoretical base and without any form of general acceptance of EBM principles by the international medical community. There are two words that can be added together to describe such actions in the Academy and they are: ‘highly’ and ‘ irresponsible’. But let us give Djulbegovic et al. their due since, until now, no one within the EBM community has come remotely close to conceding the need to conduct a detailed examination of the fundamental objections to EBM that have been consistently documented within the global medical literature. Indeed, the paper by Djulbegovic et al. clearly represents the first substantive response of EBM to its critics, as many of the core criticisms that the authors address are precisely those that have been levied against EBM in a sustained manner since its inception. Substantive, most certainly. And definitive, too, as Djulbegovic et al.’s paper is not a simple viewpoint piece outlining the personal opinions of three isolated academics. On the contrary, we may safely assume that the paper accords with the views of an extensive number of EBM enthusiasts internationally, as at its conclusion the authors confirm that ‘the content of the paper has been shaped by the ideas of people around the world who have freely exchanged their thoughts in contribution to the EBM debate’. Having canvassed and assimilated such views, the paper was then approved by the core leadership of EBM – Gordon Guyatt’s co-authorship certainly confirms that much. We may therefore regard the paper by Djulbegovic et al. as having been written and presented in the manner of a ‘position paper’, strategically conceived and delivered for publication not in the JECP (which has led the international EBM debate for the last 15 years and which could therefore have been objectively considered the most appropriate forum for publication), but, curiously, within the pages of Cancer Control, a learned journal certainly, but one with only a tangential historical interest in medical epistemology, Journal of Evaluation in Clinical Practice ISSN 1356-1294