Suffering and the Dimensionality of Medical Knowledge: A Critique of Evidence Based Medicine

Abstract

Evidence Based Medicine (EBM) is a recent philosophy that is highly influential in medicine. EBM is centred on the notion that medical practice should be supported by rigorous clinical research. This thesis explores a “dimensional” framework of knowledge and argues EBM results in the exclusion of certain non-scientific knowledge forms. Since these knowledge forms are essential to the realisation of medicine’s goals, EBM is holding medicine back.

I frame the primary goal of medicine as to attend to suffering. There is a tendency to view the goal of medicine as the treatment of disease, but this fails to account for much of what occurs in practice. Suffering incorporates disease and also other humanistic aspects of medicine that may not be investigable in a scientific manner. Medical knowledge determines medical practice, so medicine must have knowledge of what suffering is to effectively attend to suffering. I propose a dimensional theory of knowledge that includes explicit, tacit, general and particular forms of knowledge. Explicated general knowledge includes the knowledge of science. Tacit knowledge is more readily enacted than articulated. Particular knowledge is knowledge that is applicable to specific circumstances and individuals. The existence of tacit and particular knowledge moderates the possibility and need for scientific justification and also means knowledge exists within the knower and not exclusively in abstracted forms.

EBM’s philosophical framework excludes tacit and particular knowledge in its selective recognition of explicit-generalised “evidence”. This means that EBM’s conception of knowledge is incomplete and is philosophically inadequate. Though EBM makes useful contributions to clinical research appraisal, its normative assertions of “what counts as knowing” in medicine obscures human suffering and so might harm practice. This thesis presents the foundations for an alternative philosophy to EBM that would see “EBM” reframed as “clinical epidemiology” as a remedy for EBM’s normative restriction of medical knowledge.