E B Mvs Basic Sciences
{[green I like this topic. Jason ]}
EBM: presumed methodological rigour (randomised, controlled, etc); the focus is on numbers ’ use methodological rigour and answer broad population questions (is this drug better than placebo for this given condition); ?no ‘story-telling’ ’ more an aide to decision making
- Can EBM achieve this? Sceptical argument are always available; looks at populations over individuals; i.e. can only ever say that in this population of patients we seem to have this effect ’ problems are apparent in both extending this to alternative populations and contracting it to individuals within the population studied
- {[green I’ve never understood the problem with individuals within the population, although lots of people agree with you that there is a problem there. Can you explain it to me … please?! Jason ]} —>My (?perhaps simplistic) take on the argument regarding individual benefits versus group benefits from RCTs is the claim that not all individuals who took part in the trial benefited despite the overall population benefiting (e.g. a good drug which is universally recommended such as aspirin after a heart attack has a number needed to treat of about 25 to benefit one individual with respect to their cardiovascular risk). I suppose the more dramatic way to put this is that RCT and the statistical inferences within them are not able to show whether despite the overall population benefits that there is not an unidentified (but theoretically identifiable)subpopulation of individuals that have been harmed. I am sure there are examples of this but I need to think about it. To my mind (though I need to think it through) Simpsons Paradox seems to be of interest here. Let me know if this is not an answer your question. Adam {[green Not at all simplistic. What you say makes complete sense. But it’s entirely an issue in ethics, I think, which makes it kinda a long way from your other interests. Not that that’s necessarily a bad thing. Interesting question about Simpson’s Paradox. I expect you’re right about there being something to say about that. Jason ]} I am interested in your comment regarding this as an entirely ethical issue. While agreeing with the ethical dimension of the issue I thought there was also the possibility of an epistemic line of argument here, i.e. medical decision making is by and large made at the individual level and yet the EBM methodology can only make epistemic claims at the population level (and at that only at the population studied). While making this point I am not too sure whether alternatives to EBM and objective statistical inference could fare any better in this regard {[green Right: my thought was that they wouldn’t; but maybe I was wrong ]} (although I think some would argue that the basic sciences and in particular pathophysiological rationale provide “some” level of individualisation). Perhaps it is just another argument for pluralism in decision-making? {[green Yes, good, it’s at least that. ]} Adam
- Are the basic sciences assumed or questioned? (or as per ‘scientific image’ ’ both) {[green I think it has to be both. Certainly assumed, or you could never design an experiment except by luck! And your very nice examples below show that it’s questioned. The parts that are assumed are not the same as the parts that are questioned. Now that I think about this for the first time, I think it would make an excellent research topic, although maybe not the one you’re most interested in. Jason ]} I am pretty keen on the statistical inference side of things.. but i would like to handle this at least in some form if it is at all possible. Adam
- Can EBM achieve this? Sceptical argument are always available; looks at populations over individuals; i.e. can only ever say that in this population of patients we seem to have this effect ’ problems are apparent in both extending this to alternative populations and contracting it to individuals within the population studied
Basic sciences: different rules for what is considered evidence; ‘story-telling’ is much more important
What is the best way to conceptualise the differences between these approaches? Are they differences of kind or degree? {[green Kind, surely … or humongous differences of degree. Jason ]}
How do these seemingly different approaches inter-relate? How do they rely on each other? Can EBM be seen as a test of empirical adequacy for the basic sciences? {[green Good idea. Can’t test empirical adequacy in van Fraassen’s sense, though, because NOTHING can! van Fraassen only awards empirical adequacy to theories which have passed AND WILL PASS all empirical tests past, present and future. Jason ]}
- Possible examples: beta-blockers in heart failure (pharmacologically would expect beta-blockers to harm patients with heart failure, EBM provides strong evidence that they assist ’ this has seemed to stimulate a basic science story to explain the benefit found in EBM); HRT in post-menopausal women (basic science suggest that oestrogen should be beneficial to women eg cardiovascular risk etc; EBM suggest that the would be harmful); the cox-2 story again provides a nice example (basic science story for benefit; EBM eventually highlights possible harm; increased emphasis on basic science story for why harm occurs)
- A possible argument against EBM: the EBM hierachy permits decisions to be made on small number of trials ’ not explicitly part of a larger ‘story’; RCT appears to be used as a decision making procedure, where even one large well-conducted trial can have a large effect on practice. This contrasts with the basic sciences where if a finding does not correlate with the ‘story’ or paradigm it is more likely to be rejected or refined (though it is obviously more complex than this {[green Maybe not — after all, you’re only claiming that a certain response is more likely, which is a nice weak claim. ]}). This highlights the importance of the negative arguments against RCTs wrt warrant for an individual and groups other than included in the trial (i.e. every use of EBM in clinical decision making)- unless it concurs with the basic sciences
- As a random note: on reading Paul Griffiths and Karola Stotz “Gene” draft article for the Cambridge Companion to Phil of Biology, there seems a possible similarity between the relationship between EBM and the basic sciences and the functional vs material concept of the gene… quoting from P 17 “…the classical molecular gene was a highly successful example of the research strategy of identifying a functional role, searching for the mechanism that fulfills that role at a lower level of analysis and using knowledge of that mechanism to refine understanding of function at the original (in this case phenotypic) level of analysis.”“…perhaps the line could be played out that the interaction between EBM and basic sciences displays the importance of the interplay between empiricist and realist approaches…” (as a subquestion - Is there room for all of this within Van Fraassen’s constructive empiricism?) [[green Can I separate this into two issues, please? (1) There’s the question of black-boxed science versus explanatory science. There, I agree, there’s a good parallel between EBM and the two gene ideas. (2) But EBM is much more specific than any old black-boxed empiricism. So if what you’re interested in is (1), I think you’d better talk about something other than EBM, and give it a new name. ]] Thanks Jason, (?) I may be missisng your point here, I am not particularly interested in (1) other than as a way of gaining some understanding of (2). The note was to remind me to avoid the EBM ‘bad’, basic sciences ‘good’ line of thought with the point that both play a constructive role (even if some tweaking or clarity could be sought).