Maya J. Goldenberg

Because few would object to evidence-based medicine’s (EBM) principal task of basing medical decisionmaking on the most judicious and up-to-date evidence, the debate over this prolific movement may seem puzzling. Who, one may ask, could be against evidence (Carr-Hill, 2006)? Yet this question belies the sophistication of the evidence-based movement. This chapter presents the evidence-based approach as a socio-medical phenomenon and seeks to explain and negotiate the points of disagreement between supporters and detractors. This is done by casting EBM as more than the simple application of research findings to clinical care and improved health outcomes, but rather an umbrella term that harnesses a specific set of pedagogical objectives (some rather radical) under a name that makes it difficult to argue against.

In accordance with the critical women’s health literature recounting the ways that women are encouraged to submit themselves to various sorts of health “imperatives”, I investigate the messages tacitly conveyed to women in “campaigns for the cure” and breast cancer awareness efforts, which, I argue, overemphasizes a “positive attitude”, healthy lifestyle, and cure rather than prevention of this life-threatening disease. I challenge that the message of hope pervading breast cancer discourse silences the despair felt by many women, furthers a tacit blaming for disease infliction via a rhetoric of personal responsibility, underemphasizes other cogent health determinants like environmental toxicity, and undermines legitimate critiques of current biomedical practices like widespread mammography. While finding a cure for breast cancer is a laudable and worthwhile healthcare goal that can understandably be shared by women’s health activists, corporate sponsors, and the medical community, this paper resists the current formation of campaigns for the cure and “pink ribbon activism” in general.

Because “evidence” is at issue in evidence-based medicine (EBM), the critical responses to the movement have taken up themes from post-positivist philosophy of science to demonstrate the untenability of the objectivist account of evidence. While these post-positivist critiques seem largely correct, I propose that when they focus their analyses on what counts as evidence, the critics miss important and desirable pragmatic features of the evidence-based approach. This article redirects critical attention toward EBM’s rigid hierarchy of evidence as the culprit of its objectionable epistemic practices. It reframes the EBM discourse in light of a distinction between objectivist and pragmatic epistemology, which allows for a more nuanced analysis of EBM than previously offered: one that is not either/or in its evaluation of the decision-making technology as either iconoclastic or creedal.

This paper examines the conclusions that one must draw from the finding that there are values in science. The value-ladenness of scientific claims puts the nature and role of empirical evidence into question, as seen in recent discussions in the philosophy of medicine regarding evidence-based medicine and feminist science studies, which maintains the normativity of its feminist claims. Within the critical literature and debates surrounding evidence-based medicine (EBM), one finds a championing of the lessons learned from post-positivist science studies: the evidence-based effort to ground medical decision-making in the most rigorous sources of scientific evidence obscures the social values that necessarily enter into all decision-making contexts, the complex social context of clinical practice being no exception. The critics of EBM claim that to try to derive a formal methodology governed by pre-established rules, guidelines, and hierarchies of information misplaces the contextual and social features of biomedical knowledge and practice, thereby obscuring the power interests that so problematically dictate large factions of biomedical research and practice. Yet possible relativist implications follow from this finding, and we find that the EBM critics amply criticize EBM’s tacit theory of evidence, but then fail to formulate a constructive alternative theory of evidence within this fact-value interplay. After overviewing some such criticisms of evidence-based medicine, I turn to contemporary critical science studies, especially the feminist empiricism of Lynn Hankinson Nelson and Helen Longino, for workable alternative theories of evidence within a framework of normative scientific claims. I will suggest these theories fail to guide medical decision-making because of some undesirable consequences of Quinean fact-value holism: the denial that our values have logical content and are therefore not empirically examinable relativises even these nuanced conceptions of evidence. A naturalized look at how facts and values actually interact in medical decision-making suggests that this fact/value holism is not realistic. I provide an illustrative example of a physician devising a treatment recommendation for a patient to demonstrate that in practice, facts and values intermingle in the decision-making process without indeterminacy and subsequent appeals to moral and political frameworks, as feminist empiricism suggests. In the end, value-laden evidence can retain its adjudicative force and normativity.

The once animated efforts in medical phenomenology to integrate the art and science of medicine (or to humanize scientific medicine) have fallen out of philosophical fashion. Yet the current competing medical discourses of evidencebased medicine and patient-centered care suggest that this theoretical endeavor requires renewed attention. In this paper, I attempt to enliven the debate by discussing theoretical weaknesses in the way the “lived body” has operated in the medical phenomenology literature—the problem of the absent body—and highlight how evidence-based medicine has refigured medical phenomenology’s historical nemesis, “biomedicine.” What we now need is a phenomenology of the embodied subject in the age of evidence-based medicine.