Where is the wisdom? II – Evidence‐based medicine and the epistemological crisis in clinical medicine. Exposition and commentary on Djulbegovic, B., Guyatt, G. H. & Ashcroft, R. E. (2009) Cancer Control , 16, 158–168

Evidence-based medicine (EBM) burst on the scene in 1992 [1] as a challenging, innovative and ultimately enigmatic newcomer to the stage of clinical medicine. Its challenge to blind obeisance to authority and its systematic approach to the problems posed by the rapidly expanding terrain of medical knowledge ranked high on the list of EBM’s compelling features. A critical historical review, and companion piece to this exposition and commentary [2], concluded that EBM contributed tools and resources of unprecedented importance to the practice of clinical medicine in the Age of Information, but fell short of its initially bold claims to define a comprehensive and revolutionary practice model, despite several published attempts to elaborate it. Challenges to EBM on epistemological and philosophical grounds have constituted a prominent aspect of criticisms of EBM since the 1992 proclamation. However, with few exceptions [3], responses to criticisms from the EBM camp have been confined to methodological issues pertaining to clinical research designs and to general goals and objectives [4]. Djulbegovic et al.’s [5] recent contribution constitutes the first attempt from within EBM to respond systematically to the published epistemological and philosophical challenges and, for this reason alone, deserves attention. However, our commentary is motivated not only by the historical importance of their submission. Rather we perceive clinical medicine to be in the midst of an epistemological crisis and the issues to which Djulbegovic et al. appear to be responding to be centrally related to this crisis. The stated objective of EBM has been to close the gap between research and clinical practice [6]. However, such an endeavour begs the question of what constitutes the nature of that gap, that is, the proper role of research in determining or informing clinical action. As pointed out by Tonelli [6], this in turn constitutes an epistemological question insofar as it implies, following Djulbegovic, a ‘propose(d) specific relationship between theory, evidence, and knowledge’. It defines the need for a more rigorous delineation and understanding of the scientific foundations of clinical practice. As stated by Tonelli, EBM represents a school of medical epistemology [6]. Epistemology deals with the theory of knowledge and is concerned not just with the nature but also with the limitations of knowledge. Hence, to discuss EBM within an epistemological framework we must address not only its accomplishments but also its main limitations. Epistemology deals with questions such as ‘What is knowledge?’, ‘How do we know what we know?’, ‘How is knowledge acquired?’ and ‘How does knowledge lead to wise and just action?’Among these, the latter, corresponding to the realm of ‘practical wisdom’ or ‘phronesis’ in classical Aristotelian terms, appears most salient to the issue at hand. Thus, the need to address these matters in the framework of relevant concepts of science and scientific knowledge defines the need for a ‘clinical epistemology.’ [7] We find the paper by Djulbegovic to be a convenient and timely pretext for clarifying these issues in some depth.