Miriam Solomon

Evidence-Based Medicine (EBM) developed from the work of clinical epidemiologists at McMaster University and Oxford University in the 1970s and 1980s and self-consciously presented itself as a "new paradigm" called "evidence-based medicine" in the early 1990s. The techniques of the randomized controlled trial, systematic review and meta-analysis have produced an extensive and powerful body of research. They have also generated a critical literature that raises general concerns about its methods. This paper is a systematic review of the critical literature. It finds the description of EBM as a Kuhnian paradigm helpful and worth taking further. Three kinds of criticism are evaluated in detail: criticisms of procedural aspects of EBM (especially from Cartwright, Worrall and Howick), data showing the greater than expected fallibility of EBM (Ioaanidis and others), and concerns that EBM is incomplete as a philosophy of science (Ashcroft and others). The paper recommends a more instrumental or pragmatic approach to EBM, in which any ranking of evidence is done by reference to the actual, rather than the theoretically expected, reliability of results. Emphasis on EBM has eclipsed other necessary research methods in medicine. With the recent emphasis on translational medicine, we are seeing a restoration of the recognition that clinical research requires an engagement with basic theory (e.g. physiological, genetic, biochemical) and a range of empirical techniques such as bedside observation, laboratory and animal studies. EBM works best when used in this context

_The_ _Routledge Companion to Philosophy of Medicine _is a comprehensive guide to topics in the fields of epistemology and metaphysics of medicine. It examines traditional topics such as the concept of disease, causality in medicine, the epistemology of the randomized controlled trial, the biopsychosocial model, explanation, clinical judgment and phenomenology of medicine and emerging topics, such as philosophy of epidemiology, measuring harms, the concept of disability, nursing perspectives, race and gender, the metaphysics of Chinese medicine, and narrative medicine. Each of the 48 chapters is written especially for this volume and with a student audience in mind. For pedagogy and clarity, each chapter contains an extended example illustrating the ideas discussed. This text is intended for use as a reference for students in courses in philosophy of medicine and philosophy of science, and pairs well with _The_ _Routledge Companion to Bioethics_ for use in medical humanities and social science courses.

Naturalistic epistemologists frequently assume that their aim is to identify generalities (i.e. general laws) about the effectiveness of particular reasoning processes and methods. This paper argues that the search for this kind of generality fails. Work that has been done thus far to identify generalities (e.g. by Goldman, Kitcher and Thagard) overlooks both the complexity of reasoning and the relativity of assessments to particular contexts (domain, stage and goal of inquiry). Examples of human reasoning which show both complexity and contextuality are given. The paper concludes with a discussion of the kind of multivariate model of reasoning that naturalistic epistemologists can use to evaluate processes and methods for specific domains.

: Harry Collins and Trevor Pinch's introductory text, The Golem: What Everyone Should Know About Science (1993), includes a controversy about the significance of pseudosexual behavior in the parthenogenetic whiptail lizard. Collins and Pinch, basing their account on the work of Greg Myers (1990), claim that "in this area of biology, experiments are seldom possible" and that the debate has "battled to an honorable draw." I argue that a closer look at the publications of the scientists involved shows that, at least by the late 1980s, it was widely accepted that pseudosexual behavior is important for reproduction in these lizards. Moreover, a variety of experiments, as well as laboratory and field observations, proved decisive in this acceptance.

Epistemic diversity is widely approved of by social epistemologists. This paper asks, more specifi cally, how much epistemic diversity, and what kinds of epistemic diversity are normatively appropriate? Both laissez-faire and highly directive approaches to epistemic diversity are rejected in favor of the claim that diversity is a blunt epistemic tool. There are typically a number of diff erent options for adequate diversifi cation. The paper focuses on scientifi c domains, with particular attention to recent theories of smell

Trust in the practice of rational deliberation is widespread and largely unquestioned. This paper uses recent work from business contexts to challenge the view that rational deliberation in a group improves decisions. Pressure to reach consensus can, in fact, lead to phenomena such as groupthink and to suppression of relevant data. Aggregation of individual decisions, rather than deliberation to a consensus, surprisingly, can produce better decisions than those of either group deliberation or individual expert judgment. I argue that dissent is epistemically valuable, not because of the discussion it can provoke (Mill's and Longino's view about the benefit of dissent), but because dissenting positions often are associated with particular data or insights that would be lost in consensus formation. Social epistemologists can usefully pay attention to various methods of aggregation of individual opinion for their effectiveness at realizing epistemic goals.

Because the idea of consensus in contemporary philosophy of science is typically seen as the locus of progress, rationality, and, often, truth, Mill’s views on the undesirability of consensus have been largely dismissed. The historical data, however, shows that there are many examples of scientific progress without consensus, thus refuting the notion that consensus in science has any special epistemic status for rationality, scientific progress (success), or truth. What needs to be developed instead is an epistemology of dissent. I suggest that normative accounts of dissent be used as prototypes for theories of scientific rationality that can also be applied to episodes of consensus. Consensus in this case is to be treated as a special case of dissent, when the amount of dissent approaches zero. My main goal in this paper is to sketch how a normative account of dissent that aims to capture the idea of epistemic fairness can apply to situations of consensus.