73\u2005The problem of truth in EBM

Abstract

The EBM Manifesto has been developed as a response to a growing body of evidence that “suggests that most published research is more likely to be false than true.” “Serious systematic bias, error and wastage” are to blame. 9 Steps have been suggested to solve these problems. But one major step is missing: a critical review of what is meant by ‘true’. In EBM truth continues to operate hidden and almost undisputed through the linked concept of ‘bias.’ In order to solve the challenges, we face, a new deep and thorough understanding of the concept of truth is needed. Analysis. There are several important theories of truth, but the dominant way truth is conceptualized in the discourse and practice of EBM is the ideal limit theorem. As detailed by famous 19th century statistician and philosopher CS Peirce, it assumes that the ultimate and absolute truth would reveal itself in the long run, over many events in many communities now and in the future. It requires the analysis of frequent events as typically done in RCTs to make inductive inferences. In this concept of truth, bias is the deviation from the ideal limit and cognitive biases refer to failures in clinical reasoning to correctly estimate the ideal limit, the ‘true’ prevalence, incidence, and risk. But as Peirce already pointed out, the assumptions underlying the ideal limit theorem are largely metaphysical; they can be neither proven nor refuted empirically. The problem is that the ideal limit is based on a materialist view born out of classic physics. It requires a belief that human interest is just epiphenomenal, that patients and clinicians behave like dices or billiard balls, beings without internal life tending towards ideal limits as the rules ‘out there.’ It also assumes that a full separation between observers and research participants is possible and that reality is stable and deterministic. We could very well proclaim that these beliefs are justified as EBM has been so successful. However, the ideal limit may also be the cause of challenges as stated in the EBM manifesto. Solution. It is time to update our truth concept and accompanying statistics from materialistic classic physics to more modern views including quantum physics, which has already made some interesting contributions to explain probability judgement errors. We need a new framework that is capable of incorporating a view on reality that is less deterministic and includes human agency instead of discarding it as epiphenomenal. In any case, in order to prevent unwarranted relativism in a post truth world and make better inferences in clinical practice, a new generation of clinicians and the wider EBM community could benefit from a closer analysis of its existing assumptions about truth, validity, and reality.