Maya J. Goldenberg

Iconoclast or creed?: objectivism, pragmatism, and the hierarchy of evidence.

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.

Philosophy, ethics, medicine and health care: the urgent need for critical practice

Reader in Applied Philosophy, Department of Interdisciplinary Studies, MMU Cheshire, Crewe, UK Director, University of Toronto Joint Centre for Bioethics, Toronto, Ontario, Canada Assistant Professor, Department of Philosophy, University of Guelph, Guelph, Ontario, Canada Assistant Professor, Department of Philosophy and Religious Studies, Old Dominion University, Norfolk, Virginia, USA Assistant Professor, Department of Philosophy, Dalhousie University, Halifax, Nova Scotia, Canada

Reason and value: making reasoning fit for practice

Reader in Applied Philosophy, Department of Interdisciplinary Studies, MMU Cheshire, Crewe, UK Assistant Professor, Department of Philosophy and Religious Studies, Old Dominion University, Norfolk, VA, USA Associate Professor, Department of General Practice, University of Auckland, Auckland, New Zealand Director, University of Toronto Joint Centre for Bioethics, Toronto, ON, Canada Assistant Professor, Department of Philosophy, University of Guelph, Guelph, ON, Canada Assistant Professor, Department of Philosophy, Dalhousie University, Halifax, NS, Canada Professor of Values in Health Care, Associate Director, Social Dimensions of Health Institute, University of Dundee, Dundee, UK Research Fellow, King’s College Centre for Humanities and Health/Department of Philosophy; King’s College London, London, UK

Just regionalisation: rehabilitating care for people with disabilities and chronic illnesses

BackgroundRegionalised models of health care delivery have important implications for people with disabilities and chronic illnesses yet the ethical issues surrounding disability and regionalisation have not yet been explored. Although there is ethics-related research into disability and chronic illness, studies of regionalisation experiences, and research directed at improving health systems for these patient populations, to our knowledge these streams of research have not been brought together. Using the Canadian province of Ontario as a case study, we address this gap by examining the ethics of regionalisation and the implications for people with disabilities and chronic illnesses. The critical success factors we provide have broad applicability for guiding and/or evaluating new and existing regionalised health care strategies.DiscussionOntario is in the process of implementing fourteen Local Health Integration Networks (LHINs). The implementation of the LHINs provides a rare opportunity to address systematically the unmet diverse care needs of people with disabilities and chronic illnesses. The core of this paper provides a series of composite case vignettes illustrating integration opportunities relevant to these populations, namely: (i) rehabilitation and services for people with disabilities; (ii) chronic illness and cancer care; (iii) seniors health; (iv) community support services; (v) childrens health; (vi) health promotion; and (vii) mental health and addiction services. For each vignette, we interpret the governing principles developed by the LHINs – equitable access based on patient need, preserving patient choice, responsiveness to local population health needs, shared accountability and patient-centred care – and describe how they apply. We then offer critical success factors to guide the LHINs in upholding these principles in response to the needs of people with disabilities and chronic illnesses.SummaryThis paper aims to bridge an important gap in the literature by examining the ethics of a new regionalisation strategy with a focus on the implications for people with disabilities and chronic illnesses across multiple sites of care. While Ontario is used as a case study to contextualize our discussion, the issues we identify, the ethical principles we apply, and the critical success factors we provide have broader applicability for guiding and evaluating the development of – or revisions to – a regionalised health care strategy.

Public Misunderstanding of Science? Reframing the Problem of Vaccine Hesitancy

Public resistance towards scientific claims regarding vaccine safety is widely thought to stem from public misunderstanding (or ignorance) of science. Repeated failures to alleviate this ignorance make the problem of vaccine hesitancy seem intractable. I challenge this presumption of knowledge deficit and reinterpret vaccine hesitancy to be a problem of public mistrust of scientific experts and institutions. This finding invites new corrective measures: self-scrutiny by our scientific and governmental bodies regarding their own credibility as well as investment in dialogical rather than didactic communicative outreach to vaccine hesitant members of the public. Without the oppositional framing of the problem as a conflict of science versus ignorance, there is more room for conciliation of public health agendas with the concerns of the lay public.

The Nature of Evidence in Evidence-Based Medicine: Guest Editors' Introduction

164 WILLIAM HARVEY, the 17th-century English physician and champion of Enlightenment ideals, captured the intellectual passage from medievalism to modernity with this instructive remark:“It is base to receive instructions from others’ comments without examination of the objects themselves, especially as the book of nature lies so open and is so easy of consultation” (quoted in Rawlins 2008, p. 1).Today, the Harveian appeal to empirical evidence and the critical examination of conventional practices still resonates among health researchers and practitioners; however, the alleged ease of access to the empirical world has proven more constrained than Harvey suggested. The introduction of evidence-based medicine (EBM) to the medical world initially reflected an anti-authoritarian spirit similar to Harvey’s. In the Evidence Based Medicine Working Group’s programmatic 1992 JAMA article, “Evidence Based Medicine:A NewWay of Teaching the Practice of Medicine,” EBM was framed as “the way of the future”: a radical new framework for clinical medicine, where junior clinicians would eschew the advice of senior colleagues and instead directly consult the research literature in order to inform

Virtue, progress and practice.

Reader in Applied Philosophy, Department of Interdisciplinary Studies, MMU Cheshire, Crewe, UK and Visiting Professor of Philosophy as Applied to Medicine, University of Buckingham, Uk Assistant Professor, Department of Philosophy and Religious Studies, Old Dominion University, Norfolk, VA, USA Associate Professor, Department of General Practice, University of Auckland, Auckland, New Zealand Director, University of Toronto Joint Centre for Bioethics, Toronto, ON, Canada Assistant Professor, Department of Philosophy, University of Guelph, Guelph, ON, Canada Assistant Professor, Department of Philosophy, Dalhousie University, Halifax, NS, Canada Professor of Values in Health Care, Associate Director, Social Dimensions of Health Institute, University of Dundee, Dundee, UK

How can Feminist Theories of Evidence Assist Clinical Reasoning and Decision-making?

While most of healthcare research and practice fully endorses evidence-based healthcare, a minority view borrows popular themes from philosophy of science like underdetermination and value-ladenness to question the legitimacy of the evidence-based movement’s philosophical underpinnings. While the feminist origins go unacknowledged, those critics adopt a feminist reading of the “gap argument” to challenge the perceived objectivism of evidence-based practice. From there, the critics seem to despair over the “subjective elements” that values introduce to clinical reasoning, demonstrating that they do not subscribe to feminist science studies’ normative program—where contextual values can enable good science and justified decisions. In this paper, I investigate why it is that the critics of evidence-based medicine adopt feminist science’s characterization of the problem but resist the productive solutions offered by those same theorists. I suggest that the common feminist empiricist appeal to idealized epistemic communities is impractical for those working within the current biomedical context and instead offer an alternate stream of feminist research into the empirical content of values (found in the work of Elizabeth Anderson and Sharyn Clough) as a more helpful recourse for facilitating the important task of legitimate and justified clinical decision-making. I use a case study on clinical decision-making to illustrate the fruitfulness of the latter feminist empiricist framework.

Whose social values? Evaluating Canada’s ‘death of evidence’ controversy

With twentieth- and twenty-first-century philosophy of science’s unfolding acceptance of the nature of scientific inquiry being value-laden, the persistent worry has been that there are no means for legitimate negotiation of the social or non-epistemic values that enter into science. The rejection of the value-free ideal in science has thereby been coupled with the spectres of indiscriminate relativism and bias in scientific inquiry. I challenge this view in the context of recently expressed concerns regarding Canadas death of evidence controversy. The worry, raised by Stathis Psillos, is that as constructivist accounts of science demoted the previously secure status of evidence for drawing justified conclusions in science, we were left with no rational delineation between the right and wrong values for science. The implication for the death of evidence controversy is that we may have no rational grounds for claiming that the Canadian Government is wrong to interfere with scientific enterprise. But he does offer another avenue for reaching the conclusion that the wrong social values are directing the current stifling of some sectors of Canadian science. Psillos draws from standpoint epistemologies to devise a salient defence of ‘valuing evidence’ as a universalizable social value. That is, government bodies ought to enable scientific research via adequate funding as well as political non-interference. In this paper, I counter that (i) non-epistemic values can be rationally evaluated and that (ii) standpoint epistemology’s universalizable standpoint provides an inadequate framework for negotiating social values in science. Regarding (i), I draw from the evidence-based medicine debate in philosophy of medicine and from feminist empiricist investigations into the science–values relationship in order to make the argument for empirically driven value arbitration. If social values can be rationally chosen in the context of justification, then we can have grounds for charging the Canadian leadership with being ‘at war with science’. (ii) I further argue that my recommended empiricist methodology is preferable to Psillos’s search for universalizable perspectives for negotiating social values in science because the latter method permits little more than the trivial conclusion that evidence is valuable to science.

Defining ''quality of care'' persuasively

As the quality movement in health care now enters its fourth decade, the language of quality is ubiquitous. Practitioners, organizations, and government agencies alike vociferously testify their commitments to quality and accept numerous forms of governance aimed at improving quality of care. Remarkably, the powerful phrase “quality of care” is rarely defined in the health care literature. Instead it operates as an accepted and assumed goal worth pursuing. The status of evidence-based medicine, for instance, hinges on its ability to improve quality of care, and efforts are made by both proponents and detractors to unpack the contents and outcomes of evidence-based practice while the contents of “quality of care” are presumed to be understood. Because the goals of medicine are far from obvious, this paper investigates the neglected term, “quality of care,” in an effort to understand what it is that health care practices are so uncritically assumed to be striving for. Finding lack of consensus on the terminology in the quality literature, I propose that the term operates rhetorically by way of persuasive appeal (and lack of descriptive meaning). Unsatisfied that “quality of care” operates as a mere buzzword in morally contentious debates over resource allocation and duties of care, I implore health care communities to go beyond mere commitments to quality and, instead, to focus attention on the difficult task of specifying what counts as quality care within an economically constrained health care system.