Despite a rich theoretical and clinical history, psychodynamic child and adolescent psychotherapy has been slow to engage in the empirical assessment of its effectiveness. This systematic review aims to provide a narrative synthesis of the evidence base for psychodynamic therapy with children and adolescents. Building on two earlier systematic reviews, which covered the period up to 2017, the current study involved two stages: an updated literature search, covering the period between January 2017 and May 2020, and a (...) class='Hi'>narrative synthesis of these new studies with those identified in the earlier reviews. The updated search identified 37 papers. When combined with papers identified in the earlier systematic reviews, this resulted in a combined total of 123 papers. The narrative synthesis of findings indicates that there is evidence of effectiveness for psychodynamic therapy in treating a wide range of mental health difficulties in children and adolescents. The evidence suggests this approach may be especially effective for internalizing disorders such as depression and anxiety, as well as in the treatment of emerging personality disorders and in the treatment of children who have experience of adversity. Both the quality and quantity of empirical papers in this field has increased over time. However, much of the research demonstrates a range of methodological limitations, and only 22 studies were Randomized Controlled Trials. Further high-quality research is needed in order to better understand the effectiveness of psychodynamic psychotherapy for children and young people. (shrink)

While evidence-based medicine (EBM) is often accused on relying on a paradigm of 'absolute truth', it is in fact highly consistent with Karl Popper's criterion of demarcation through falsification. Even more relevant, the first three steps of the EBM process are closely patterned on Popper's evolutionary approach of objective knowledge: (1) recognition of a problem; (2) generation of solutions; and (3) selection of the best solution. This places the step 1 of the EBM process (building an answerable question) (...) in a pivotal position for the understanding of the whole process, and underscores a few aspects which are often overlooked in EBM courses. First in this step internal evidence (including personal expertise) must be appraised and integrated in the problem. Second, issues of applicability of the possible solution should be anticipated. Third, and possibly more important, the goal of the intervention should be set at this stage (typically by choosing the outcome in a PICO question). Depending whether or not goals depend on the goals of others, and whether they concern others' voluntary behaviour, goals may be classified as self-serving, moral, altruistic or moralistic. Thus, delicate ethical questions must be addressed at this stage, which means that patient preferences and values must be carefully sought, so that empathy, counselling and narrative medicine must be mastered to be able to formulate correctly an answerable question. The need to modify the current description of the EBM process to increase the recognition of implicit assumptions and increase the consistency of this model is discussed. (shrink)

Objective: To examine the role of explainability in machine learning for healthcare (MLHC), and its necessity and significance with respect to effective and ethical MLHC application. Study Design and Setting: This commentary engages with the growing and dynamic corpus of literature on the use of MLHC and artificial intelligence (AI) in medicine, which provide the context for a focused narrative review of arguments presented in favour of and opposition to explainability in MLHC. Results: We find that concerns regarding explainability (...) are not limited to MLHC, but rather extend to numerous well-validated treatment interventions as well as to human clinical judgment itself. We examine the role of evidence-based medicine in evaluating unexplainable treatments and technologies, and highlight the analogy between the concept of explainability in MLHC and the related concept of mechanistic reasoning in evidence-based medicine. Conclusion: Ultimately, we conclude that the value of explainability in MLHC is not intrinsic, but is instead instrumental to achieving greater imperatives such as performance and trust. We caution against the uncompromising pursuit of explainability, and advocate instead for the development of robust empirical methods to successfully evaluate increasingly inexplicable algorithmic systems. (shrink)

Drawing on previous empirical research, we provide an exemplary narrative to illustrate how patients have experienced hospital care organized according to evidence‐based fast‐track programmes. The aim of this paper was to analyse and discuss if and how it is possible to include patients’ individual perspectives in an evidence‐based practice as seen from the point of view of nursing theory. The paper highlights two conflicting courses of development. One is a course of standardization founded on (...) class='Hi'>evidence‐based recommendations, which specify a set of rules that the patient must follow rigorously. The other is a course of democratization based on patients’ involvement in care. Referring to the analysis of the narrative, we argue that, in the current implementation of evidence‐based practice, the proposed involvement of patients resembles empty rhetoric. We argue that the principles and values from evidence‐based medicine are being lost in the transformation into the current evidence‐based hospital culture which potentially leads to a McDonaldization of nursing practice reflected as ‘one best way’. We argue for reviving ethics of care perspectives in today's evidence practice as the fundamental values of nursing may potentially bridge conflicts between evidence‐based practice and the ideals of patient participation thus preventing a practice of ‘McNursing’. (shrink)

Despite the entrenched acceptance of normal science in health care, it appears that authoritative, positivist, linear, risk averse, certainty-based thinking can only get us so far along the route of optimum health. This paper examines labor and childbirth as a paradigm case of a complex adaptive system (CAS) and offers the example of techniques used in a master-level course on normal childbirth to illustrate how maternity care clinicians can be introduced to complexity-based thinking through reflexive analysis of real (...) life clinical narratives. It suggests that these techniques might be used as a basis for answering the question, what is likely to work for this person, in this situation, given the range of evidence, and given their values and beliefs, my values and beliefs, and my clinical skills and knowledge? Topics discussed in this paper include complexity, pregnancy, and childbirth; mainstreaming complexity-focused decision making in maternity care; and using story in practice. In conclusion, complexity theory appears to offer a good explanatory model for pregnancy and childbirth, both in general, and for specific individuals. Future work in this area should examine the efficacy and limits to formal story telling in maternity care, with the aim of increasing optimal maternity care for mothers and babies, and for the staff and organizations that deliver the care. (PsycINFO Database Record (c) 2010 APA, all rights reserved). (shrink)

The deconstructing angel: nursing, reflection and evidence‐based practice This paper explores Jacques Derrida's strategy of deconstruction as a way of understanding and critiquing nursing theory and practice. Deconstruction has its origins in philosophy, but I argue that it is useful and relevant as a way of challenging the dominant paradigm of any discipline, including nursing. Because deconstruction is notoriously difficult to define, I offer a number of examples of deconstruction in action. In particular, I focus on three critiques (...) of reflective practice by the meta‐narrative of evidence‐based practice (EBP) and attempt to show how those critiques can be directed back at EBP itself. I conclude with the observation that EBP is open to many of the criticisms that it directs at other discourses, including problems of a lack of empirical evidence, of distortions due to memory, and of falsification of the ‘facts’. (shrink)

This paper aims to queer evidence‐based practice by troubling the concepts of evidence, knowledge and mental illness. The evidence‐based narrative that emerged within biomedicine has dominated health care. The biomedical notion of ‘evidence’ has been critiqued extensively and is seen as exclusive and limiting, and even though the social constructionist paradigm attempts to challenge the authority of biomedicine to legitimate what constitutes acceptable evidence or knowledge for those experiencing mental illness, biomedical notions (...) of evidence appear to remain relatively intact. Queer theory offers theoretical tools to disrupt biomedical norms and challenges biomedical normativity to indicate how marginalisation occurs when normative truths about mental health classify those who differ from the norm as ‘ill’ or ‘disordered’. Queer theory's emphasis on normativity serves the political aim to subvert marginalisation and bring about radical social and material change. Reference will be made to mental health subjects within each discourse by indicating how the body acts as a vehicle for knowing. Deleuzian notions of the rhizome are used as metaphor to suggest a relational approach to knowledge that does away with either/or positions in either biomedical, or queer knowledge to arrive at a both/and position where the biomedical, constructionist and queer are interrelated and entangled in needing the other for their own evolution. However, queer does not ask for assimilation but celebrates difference by remaining outside to disrupt that which is easily overlooked, assumed to be natural or represented as the norm. The task of queer knowledge is to do justice to the lives lived in the name of evidence‐based practice and demands that we consider the relations of power where knowledge is produced. This pursuit creates different knowledge spaces where we identify new intersections that allow for socially just understandings of knowing or evidence to emerge. (shrink)

The trend to centralization of the Mizrahi narrative has become an integral part of the nationalistic, ethnic, religious, and ideological-political dimensions of the emerging, complex Israeli identity. This trend includes several forms of opposition: strong opposition to "melting pot" policies and their ideological leaders; opposition to the view that ethnicity is a dimension of the tension and schisms that threaten Israeli society; and, direct repulsion of attempts to silence and to dismiss Mizrahim and so marginalize them hegemonically. The Mizrahi (...) Democratic Rainbow [The Keshet], the most prominent proponent and representative of this trend, was established in the 1990s with the intention of being a leading civic and political body in Israeli society. While it was the Mizrahi worldview that led to selection of the organization's name and aims, their vision was to be involved in social struggle on behalf of other groups in Israeli society. Since it was established, The Keshet has aimed to function as an assertive, long-term alternative coalition exerting influence, power, and pressure on the Israeli narrative network. And, indeed, the organization has succeeded in disrupting Israeli discourse, principally, by challenging the ideological foundations of the Zionist meta-narrative. Nearing the end of the first decade of the 21st century and nearly a decade since it was established, The Keshet not only represents the most current wave of Mizrahi discourse, it has changed it to such a great degree that it is impossible to ignore its influence. Further, this alternative narrative may have significant potential to advance the internal Jewish discourse so fundamental at this time given the changing Israeli situation and regional conditions. And, while it is possible to view The Keshet and this new narrative as a continuation of the Mizrahi struggle, as a narrative The Keshet's agenda represents a post-colonial perspective and multi-cultural alternative to Zionism as a social vehicle. Amidst all of this, The Keshet continues to offer concrete proposals to change the Jewish character of the state as well as its internal and external relations. One of the primary goals of this study was to examine the rise of the Mizrahi narrative over the last two decades and the new Mizrahi discourse in Israeli society. More specifically, the study sought to attain an in-depth understanding of the central narrative created and represented by The Keshet. An additional goal was to investigate the influence of The Keshet's activity and the narrative it constructed in regard to other narratives. In particular, the study focused on The Keshet's opposition to the central Zionist narrative that infuses civic, political, and academic frameworks in Israel. Accordingly, the primary research questions investigated in the study sought to determine: What has been the influence of the Mizrahi Democratic Rainbow on the Mizrahi narrative in Israel? And, what are implications of such influence for the central Zionist narrative? Methodologically, the study was based on narrative and comparative analyses of texts from different periods of the older and newer Mizrahi narratives. The corpus included two types of texts: First, academic texts and opinion pieces, both philosophical and programmatic in nature, published in magazines, journals, books, as well as position papers; second, all of the texts published by prominent and influential figures who charted the path of The Keshet or led it organizationally and/or intellectually over the last twenty years (e. g., Yehudah Shenhav, Yossi Yona, Moshe Krief among others). All texts were examined by means of philosophical, historical and critical hermeneutic tools. This analysis revealed different levels of Mizrahi and civic discourse in Israel as well as among The Keshet's founders and leading ideologues. The study was based on a three stage process model, developed for purposes of this study, for investigation and analysis of the new Mizrahi narrative as well as other oppositional narratives, in particular opposition to the hegemonic meta-narrative. The stages are: issuing the challenge, dissolution and, liberation; that is, liberation is the measure of the ultimate success of the struggle for narrative change. Such change is not based on success in the field, but rather on a radical, fundamental reversal of thought, discourse patterns, stylistic structures, as well as forms of questioning - in this case of taken-for-granted racist mechanisms. However, the principal change is in achieving a deep, inner de-legitimization of the signifiers, categories, and reproductions of all manner of mockery that are based on immoral colonialist processes that are reinforced by regimes of fear and intimidation whose self-destruction began upon their very creation. This three stage model charts the course of the oppositional Mizrahi narrative from: accounting for the past (passing judgment on the so-called historic colonialist Zionism) to writing a new (pure Mizrahi) history and creation of a Mizrahi-Arab identity separate from the Ashkenazic, identified as Zionist. Contemporary post-colonialist discourse is integral in these stages. Such a perspective has been transformed by transitions from - binarism to hybridity, Orientalism to Occidentalism, the politics of "liberation" to "constructive" politics, from the history of consciousness to the history of change, as well as from nationalist to post-nationalist questions. Fundamentally, according to this approach, political and other struggles for the emerging narrative of Mizrahi (or Arab) history seek to centralize it in society and weave it amidst the models of multiculturalism. Undertaken in parallel, the central characteristics of all these stages are borrowed from countries in which the need for national reconciliation led to renunciation of apartheid and racist policies and historical judgment of the hegemony supported by racist leaders. In addition, these three moves were undertaken in Keshet and its ideologues by means of substantive symbolic violence directed at the hegemonic Ashkenazic discourse, which included creation of hatred of it, use of stereotypes the opposite of oppressive discourse, and adoption of an arrogant point of view toward it. This stands in stark contrast to the claims of the self-proclaimed new Mizrahi stance of a discourse established on purely ethical grounds that sought to cleanse itself of these very same oppressive elements. The model developed for and demonstrated in this study allows for analysis of oppositional narratives in which the libratory stage evolves into a form of entrapment, as appears to be occurring to the new Mizrahi discourse. This conclusion is based on the observations shared by many Keshet proponents including leading intellectuals who worked on the manifestos that were the subject of criticism from the Zionist camp. The study identified and defined the following six interwoven strata, which for purposes of explication are each discussed in a separate chapter: The first chapter presents a general theoretical discussion of the issue of the narrative and the inter-narrative struggle that has become central and applicable in various ways in the latest generation (e. g., anthropologically, hermeneutically, and philosophically). The analysis surveys different discussions in the inter-narrative struggle and locates them in the contexts, relations, and meanings derived from, representing, and indeed reproducing the narrative of national identity. The second chapter includes a historical survey of the older Mizrahi struggle that existed prior to the ascendance of the new Mizrahi narrative. Initially, Mizrahi discourse focused on expressing the ethnic protest that grew in years to follow. These feelings of discrimination and social distancing of the immigrants from Islamic countries gave birth to expressions of protest, the most prominent of which were Wadi Salib and the Black Panther Movement's various activities. The research literature contains many explanations for the exacerbation of the ethnic problem and creation of a situation that could not be ignored. The consensus academic view reached at the end of the 1970s identified a number of primary factors for this situation: the existence and extensive numbers of different ethnic groups; the relative or absolute segregation of frameworks within which members of these ethnic groups lived and acted; and the significant overlap between socio-economic status and feelings of discrimination retained by members of the Mizrahi group due years of neglect by the Ashkenazic establishment, the strengthening of Mizrahi social, cultural, and political power, as well as the emergence of a Mizrahi elite that identified with Mizrahi problems. The severe consequences of feelings of discrimination were expressed in a long series of events, such as: rioting by residents of the Rehovot Sharayim neighborhood in 1956; events of Wadi Salib in Haifa in 1959; and a chain of activities involving the Black Panthers in the 1970s. Protest was also an aspect of the "tent movement" in the 1970s and 1980s. Political activities were advanced by the Tami Movement that competed in the election for the 10th Knesset in 1981 and the Shas Movement that has continued to garner political power since being found in 1984. The 1980s and 1990s were characterized as the era of radical consciousness of Mizrahi discourse as well as by the rise to power, in consecutive order, of the political parties – Tami, Shas, and the Mizrahim HaHadashim [the New Mizrahi]. The latter party laid the foundations of the new radical Mizrahi discourse from which emerged such cultural activities as: Iton Aher [A Different Newspaper]; Bimat Kivon Aher [Another Direction Forum]; Efir'yon journal; the Halah Organization for Education in Neighborhoods, Development Towns, and Villages; Kedma; the newspaper – Patish [Hammer]; and, eventually the establishment of Keshet. The third chapter presents an examination of the materialization of the inter-narrative struggle in the case of Israel, with a specific focus on The Keshet and the new Mizrahi narrative advanced by it and intellectuals. The Keshet ideology is examined in the context of its grounding in post-colonial thought, especially that of Edward Said; the directions proposed by Ella Shohat and her followers; the central thinkers of the narrative in Israel in the last decade; and the harsh critique leveled at the Ashkenazic-Zionist narrative. The practical steps proposed for implementation within the multicultural model are also examined. Here the effort to reduce the centrality of Zionism while revealing its oppressive mechanisms was undertaken in parallel with use of these mechanisms in order to create a Mizrahi space with broad margins inclusive of alternative forms of Israeli identity in the Middle East and in conjunction with Arabs within and beyond Israel. Mizrahi traditionalism is examined in the fourth chapter in two particular respects. First, the criticism of the new Mizrahi narrative leveled by the renewed view and, second, the implications of the alternative in terms of creating a Mizrahi space that does not oppose Zionism. Rather, in opposing the post-colonialist perspective, this renewed traditionalist perspective criticizes as well as values Zionism. This space seeks to be both Jewish and Mizrahi. It does not detach itself from nationalist Zionism but rather views itself as a continuation of this tradition and, accordingly, is an effort to develop a next stage in its development. For example, an essential dimension of the traditionalist perspective, "commitment," is considered in this stage to be a fertile basis for dialogue with the past and as an anchor for contemporary interpretation of Mizrahi and other Jews' identities in Israel. The fifth and sixth chapters deal with all of the vectors of criticism directed at the new Mizrahi narrative, including its ideological foundations, philosophical stance, as well as intellectual and practical basis in the Israeli sphere in the face of Palestinian nationalism. These vectors of criticism from within and beyond The Keshet deal with issues, such as, the meaning of the movement's activities and the narrative that it offers regarding questions of Israeli identity, Israeli collective memory, and Mizrahi self-perception. At the same time, it must confront the capitalist neo-liberal narrative in a global world and thrive in a context in which it must make itself manifest amidst oppositional narratives. The final chapter presents a comprehensive, critical analysis of the new Mizrahi narrative. It does so by means of a theoretical model that examines it as an oppositional narrative – one that seeks to challenge the hegemonic meta-narrative, to dissolve the boundaries of the narrative discourse, and to propose liberation and redemption that may led to entrapment amidst a changing, a-dichotomous realities (e. g., global economic development in the face of Zionist nationalisms that display ideological strength as well as development of the sense of being an Israeli that maintains its vitality and continuity while being constituted by sectors that challenge being a Mizrahi, such as co-ethnic subjects. The Keshet's influence is dramatic and extends in a number of central directions. Its political activity and non-entry into the domains of the Israeli parliament granted the movement significant power in civic discourse and contributed to changing the persona of the Mizrahi discourse; for example, from political-party struggles over budgets and obtaining shares of the regime to changing the face of Israeli society and the centrality of the Mizrahi narrative. This change included deconstructing the Ashkenazic narrative and constructing comprehensive Ashkenazic-Zionist guilt, as evident in the Ehud Barak's request for collective forgiveness. This was accomplished through the participation of leading members of Keshet who appeared in prominent intellectual forums and engaged in lively discourse - principally in academic, social, and media domains. Such participation gave new meaning to various aspects of Israeli society while establishing different models of multiculturalism. The rise of the new Mizrahi narrative is a significant marker in the inter-narrative struggle as it represents a desire for separate or hybrid identities. And, the deep probing of the narrative constructed by leaders of The Keshet and those who identify with the movement produced a number of clear ways to distinguish it from the old Mizrahi struggle, whose history was portrayed through social protests, in a manner similar to linear vectors marked with wars and elections. The old Mizrahi struggle selected the traditional tactical struggle identified usually with social and political movements that seek to change political, social, and economic reality - from the bottom up. Their primary demand was to change decisions as well as the division of social goods and resources. Hence, this older period of struggle was not aimed at opposing the ideological foundations of the hegemonic narrative nor did it seek to undermine in a radical manner the unique nature of the state of Israel as a revolutionary solution for the problems of the Jews according to the Zionist approach, as a national home for the Jewish people, and recognition of the right to an preferred and meta-definition of Jewish nationalism. In contrast, the top down struggle advanced by the new narrative is part of an ideological movement led by the educated that is assertive and ground in post-colonialist theory. Accordingly, it was critical of the techniques and mechanisms of oppression as well as sought to attack the Zionist ideological foundations and to reveal its racist operations and the regimes that have preserved it so efficiently for many years. The uniqueness of this narrative is the intellectual offensive that continues to be advanced and, in parallel, development of the discourse struggle in Israel concerning the justification for Zionism and the concrete political proposal that Jews reject the taken-for-granted status of it as an ideology. This new narrative recognizes the historic difficulties of subversion as an emancipatory and, principally, moral effort. In addition, the new Mizrahi narrative shares the foundations and narrative of Palestinian victimization. In its radical version, the new Mizrahi narrative seeks to connect to the Palestinian narrative in order to create a new space here. According to this version, this action will take place gradually. The first stage will be characterized by opposition to Western European, Ashkenazic Zionism. The Eurocentric Zionism will surrender in the second stage, to be followed in the last stage by creation of a coalition of Jews and Arabs that will be establish through concrete actualization of the refugee status and victimization that is shared by both Palestinians and Mizrahim (whether as Mizrahim or Jewish-Arab). Not a speculative academic exercise, the goal sought by this narrative is delineate and to achieve a multicultural model in which equality, liberty, and social justice will overcome the nationalism and colonialism of either side; that is it will be neither Zionist nor Jewish. Thus, this approach stresses what is shared (e.g., acceptance of the Arab space and not a rejection of it; the legitimacy of the Arab language and culture). This is part of detachment from and historic judgment of the colonialist Zionist enterprise. This possibility includes moral elements that remove the evil and harm caused by Zionism for many years as well as inner cleansing – primarily among Ashkenazim – of attitudes towards Jews and non-Jews. Though, in this regard, it should be noted that, to date, the new narrative has not made similar claims that Palestinians undergo a similar process. The assumption seems to be that this should be tested, that the coalition proposed is a possibility that will be recognized by the Palestinians, and that they are prepared to undergo a similar, shared moral process that involves negating the state of Israel as a Jewish, Western state, a state of the Jewish people, and not only for those who live within it. These Mizrahi thinkers conducted a significant move through deconstruction and substitution of the Eurocentric narrative with a multi-cultural proposal that is optimistic and even attractively naïve. Today, they acknowledge that they did not take into account Palestinian nationalist violence directed to citizens, the traditionalist alternative, and widespread opposition within the Mizrahi community toward what is perceived to be Mizrahi seclusion. They also did not take into account the harsh criticism rendered by young and educated Mizrahim who claim that they were born into a complex, multi-dimensional, multi-layered identity that includes internalization of the language of the West and rules of the game of this complex identity. And, though they are critical of some of its values, this makes it difficult to mount internal emotional opposition to the West and to the globalization contained within this world. Hence, this more familiar world is preferred over the values of the Mizrahi-Arab alternative, particularly in regard to problems in the domains of democratic citizenship, stance taken toward women, and freedom of speech. Further, educated Mizrachim reject the post-colonialist perspective and are stridently critical of its dichotomization. They claim that such a division is irrelevant in a world in which older ideologies have collapsed and new spheres – such as cyberspace and others – are open to them in which they can present themselves with an Israeli identity that is not categorized as necessarily Mizrahi. (shrink)

The relationship between evidence-based medicine (EBM) and clinical judgement is the subject of conceptual and practical dispute. For example, EBM and clinical guidelines are seen to increasingly dominate medical decision-making at the expense of other, human elements, and to threaten the art of medicine. Clinical wisdom always remains open to question. We want to know why particular beliefs are held, and the epistemological status of claims based in wisdom or experience. The paper critically appraises a number of (...) claims and distinctions, and attempts to clarify the connections between EBM, clinical experience and judgement, and the objective and evaluative categories of medicine. I conclude that to demystify clinical wisdom is not to devalue it. EBM ought not be conceived as needing to be limited or balanced by clinical wisdom, since if its language is translatable into terms comprehensible and applicable to individuals, it helps constitute clinical wisdom. Failure to appreciate this constitutive relation will help perpetuate medical paternalism and delay the adoption of properly evidence-based practice, which would be both unethical and unwise. (shrink)

The end of the 1990s witnessed the development of evidence-based medicine, which proposed to screen, organize, and classify knowledge production in the health sciences. In this period, an increasing number of scientific publications started to incorporate the digital format and became easily accessible through the Internet. Since then, we have become used to the idea that there is a hierarchy in medical evidence. Its upper stratum, the gold standard of evidence, contains systematic reviews and meta-analyses of (...) randomized clinical trials. The base of such hierarchy contains case studies, clinical cases, and personal opinions.This knowledge hierarchy is not harmless. It has practical influences on... (shrink)

The present narrative review seeks to unravel where we are now, and where we need to go to delineate the active ingredients in psychotherapy delivered by conversational agents (e.g., chatbots). While psychotherapy delivered by conversational agents has shown promising effectiveness for depression, anxiety, and psychological distress across several randomized controlled trials, little emphasis has been placed on the therapeutic processes in these interventions. The theoretical framework of this narrative review is grounded in prominent perspectives on the active ingredients (...) in psychotherapy. Based on search terms derived from various theoretical perspectives, we conducted a systematic literature search of four scientific databases and identified 17 studies. Across the selected studies, three themes emerged: relationship variables, emotional venting, and cognitive factors. While methodological issues compromise the epistemic value of this evidence base, core questions also remain to be answered. Such questions include, but are not limited to, whether humans can form affectionate bonds to inanimate beings and whether these kind of mental health treatments should be understood as psychotherapy or something else. Researchers should therefore be cautious when applying theories of psychotherapy in the realm of conversational agents. We conclude the paper by introducing recommendations for future research, which we hope will help instigate methodologically sound studies in this field. (shrink)

The concept of evidence has gone unanalysed in much of the current debate between proponents and critics of evidence-based medicine. In this paper I will suggest that part of the controversy rests on an understanding of the word “evidence” that is too broad, and therefore contains the contradictions that allow both camps to defend their position and charge their adversaries. I will argue that reconciling the different meanings of the word ‘evidence’ in “evidence-based (...) medicine” should help put EBM in its rightful place. (shrink)

BackgroundExpertise has been a contentious concept in Evidence-Based Medicine. Especially in the early days of the movement, expertise was taken to be exactly what EBM was rebelling against—the authoritarian pronouncements about “best” interventions dutifully learned in medical schools, sometimes with dire consequences. Since then, some proponents of EBM have tried various ways of reincorporating the idea of expertise into EBM, with mixed results. However, questions remain. Is expertise evidence? If not, what is it good for, if anything?MethodsIn (...) this article, I describe and analyze the three historical models of expertise integration in EBM and discuss the difficulties in putting each into practice. I also examine accounts of expertise from disciplines outside of medicine, including philosophy, sociology, psychology, and science and technology studies to see if these accounts can strengthen and clarify what EBM has to say about expertise.ResultsOf the accounts of expertise discussed here, the Collins and Evans account can do most to clarify the concept of expertise in EBM.ConclusionsWith some additional clarification from EBM proper, theoretical resources from other disciplines might augment the current EBM account of expertise. (shrink)

Evidence-Based Medicine is a relatively new movement that seeks to put clinical med- icine on a firmer scientific footing. I take it as uncontroversial that medical practice should be based on best evidence-the interesting questions concern the details. This paper tries to move towards a coherent and unified account of best evidence in medicine, by exploring in particular the EBM position on RCTs (randomized controlled trials).

Evidence-Based Medicine is a relatively new movement that seeks to put clinical medicine on a firmer scientific footing. I take it as uncontroversial that medical practice should be based on best evidence—the interesting questions concern the details. This paper tries to move towards a coherent and unified account of best evidence in medicine, by exploring in particular the EBM position on RCTs.

Evidence-based medicine has always required integration of patient values with ‘best’ clinical evidence. It is widely recognized that scientific practices and discoveries, including those of EBM, are value-laden. But to date, the science of EBM has focused primarily on methods for reducing bias in the evidence, while the role of values in the different aspects of the EBM process has been almost completely ignored.

© The Author. Published by Oxford University Press on behalf of the Oxford Centre for Islamic Studies. All rights reserved. For Permissions, please email: [email protected] edited volume is based on the proceedings of an international workshop held in 2009 on the theme of ‘Material Evidence and Narrative Sources’ during the fourteenth annual gathering of the Department of Middle East Studies at Ben-Gurion University of the Negev, focused on ‘Interdisciplinary Studies of the History of Islamic Societies’. Fifteen articles (...) seek to integrate material and textual evidence for the medieval and modern Middle East, deliberately adhering to a trend of interdisciplinarity that began in the 1970s, exemplified in the approach of specific studies by Michael Cook, Leor Halevi, Peter Brown, Oleg Grabar, and Jacob Lassner, as well as in the recent publications of the editors, D. J. Talmon-Geller’s Islamic Piety in Medieval Syria: Mosques, Cemeteries and Sermons under the Zangids... (shrink)

The rapid development in healthcare technologies in recent years has resulted in the need for health services, whether publicly funded or insurance based, to identify means to maximise the benefits and provide equitable distribution of limited resources. This has resulted in the need for rationing decisions, and there has been considerable debate regarding the substantive and procedural ethical principles that promote distributive justice when making such decisions. In this paper, I argue that while the scientifically rigorous approaches of (...) class='Hi'>evidence-based healthcare are claimed as aspects of procedural justice that legitimise such guidance, there are biases and distortions in all aspects of the process that may lead to epistemic injustices. Regardless of adherence to principles of distributive justice in the decision-making process, evidential failings may undermine the fairness and legitimacy of such decisions. In particular, I identify epistemic exclusion that denies certain patient and professional groups the opportunity to contribute to the epistemic endeavour. This occurs at all stages of the process, from the generation, analysis and reporting of the underlying evidence, through the interpretation of such evidence, to the decision-making that determines access to healthcare resources. I further argue that this is compounded by processes which confer unwarranted epistemic privilege on experts in relation to explicit or implicit value judgements, which are not within their remit. I suggest a number of areas in which changes to the processes for developing, regulating, reporting and evaluating evidence may improve the legitimacy of such processes. (shrink)

Evidence-based approaches to policy-making are growing in popularity. A generally embraced view is that with the appropriate evidence at hand, decision and policy making will be optimal, legitimate and publicly accountable. In practice, however, evidence-based policy making is constrained by a variety of problems of evidence. Some of these problems will be explored in this article, in the context of the debates on evidence from which they originate. It is argued that the source (...) of much disagreement might be a failure to addressing crucial philosophical assumptions that inform, often silently, these debates. Three controversial questions will be raised which appear central to some of the challenges faced by evidence-based policy making: firstly, how do certain types of facts candidate themselves as evidence; secondly, how do we decide what evidence we have, and how much of it; and thirdly, can we combine evidence. In addressing these questions it will be shown how a philosophically informed debate might prove instrumental in clarifying and settling practical difficulties. (shrink)

This paper1 aims to develop a model of practitioner narrative competence specifically for mental health care. I begin by considering the status of narratives as a form of evidence. Following Rita Charon and Cheryl Misak, I claim that there is no distinction to be made between evidence-based medicine and narrative medicine. I then explore Charon’s model of practitioner narrative competence, and suggest that it can be fruitfully adapted for mental health care contexts, a project (...) for which I employ Jennifer Radden and John Z. Sadler’s psychiatric ethics. This project brings together two independently promising accounts to develop what I refer to as the adapted model of... (shrink)

Kerry et al. criticize our discussion of causal knowledge in evidence-based medicine (EBM) and our assessment of the relevance of their dispositionalist ontology for EBM. Three issues need to be addressed in response: (1) problems concerning transfer of causal knowledge across heterogeneous contexts; (2) how predictions about the effects of individual treatments based on population-level evidence from RCTs are fallible; and (3) the relevance of ontological theories like dispositionalism for EBM.

The authors of this volume elucidate the remarkable role played by religion in the shaping and reshaping of narrative forms in antiquity and late antiquity in a variety of ways. This is particularly evident in ancient Jewish and Christian narrative, which is in the focus of most of the contributions, but also in some “pagan” novels such as that of Heliodorus, which is dealt with as well in the third part of the volume, both in an illuminating comparison (...) with Christian novels and in an inspiring rethinking of Heliodorus's relation to Neoplatonism. All of these essays, from different perspectives, illuminate the interplay between narrative and religion, and show how religious concerns and agendas shaped narrative forms in Judaism and early Christianity. A series of compelling and innovative articles, all based on fresh and often groundbreaking research by eminent specialists, is divided into three large sections: part one deals with ancient Jewish narrative, and part two with ancient Christian narrative, in particular gospels, acts, biographies, and martyrdoms, while part three offers a comparison with “pagan” narrative, and especially the religious novel of Heliodorus, both in terms of social perspectives and in terms of philosophical and religious agendas. Like the essays collected by Marília Futre Pinheiro, Judith Perkins, and Richard Pervo in 2013, which investigate the core role played by narratives in Christian and Jewish self-fashioning in the Roman Empire, the present volume fruitfully bridges the disciplinary gap between classical studies and ancient Jewish and Christian studies, offers new insights, and hopefully opens up new paths of inquiry. Contributions by (in alphabetical order): Cathryn Chew, Mark J. Edwards, Erich Gruen, Vincent Hunink, David Konstan, Karen King, Dennis MacDonald, Laura S. Nasrallah, Judith Perkins, Richard Pervo, Ilaria Ramelli, Lautaro Roig Lanzillotta, Svetla Slaveva-Griffin, and Lawrence Wills. (shrink)

Evidence based medicine has been a topic of considerable controversy in medical and health care circles over its short lifetime, because of the claims made by its exponents about the criteria used to assess the evidence for or against the effectiveness of medical interventions. The central epistemological debates underpinning the debates about evidence based medicine are reviewed by this paper, and some areas are suggested where further work remains to be done. In particular, further work (...) is needed on the theory of evidence and inference; causation and correlation; clinical judgment and collective knowledge; the structure of medical theory; and the nature of clinical effectiveness. (shrink)

This paper challenges the traditional assumption that descriptive and prescriptive sciences are essentially distinct by presenting a study on the implicit normativity of the production and presentation of biomedical scientific facts within evidence-based medicine. This interdisciplinary study serves as an illustration of the potential worth of the concept of implicit normativity for bioethics in general and for integrated empirical ethics research in particular. It demonstrates how both the production and presentation of scientific information in an evidence-based (...) decision-support contain implicit presuppositions and values, which pre-structure the moral environment of the clinical process of decision-making. As a consequence, the evidence-based decision support did not only support the clinical decision-making process; it also transformed it in a morally significant way. This phenomenon undermines the assumption within much of the literature on patient autonomy that information disclosure is a conditional requirement before patient autonomy even starts; patient autonomy is already influenced during the production and presentation of information. These results imply an increased responsibility of those who produce and present evidence-based facts(i.e. scientists in general and physicians in particular). The insights of this study not only involve a different focus on both theory and practice of patient autonomy and informed consent, but they also call for a broader scope of morality than does traditional empirical research in bioethics. The concept of implicit normativity within integrated empirical ethics research calls for a strong cooperation between bioethicists and descriptive scientists, i.e., a cooperation that goes beyond the discipline-specific epistemic values and that takes place during all phases of the research process. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:How Narrative Counts in Phenomenological Models of SchizophreniaThe author reports no conflicts of interest.Rosanna Wannberg (2024) offers an intriguing and novel critique of the predominant phenomenological model of schizophrenia, the ipseity disturbance hypothesis. According to this model, which was initially proposed by Sass and Parnas (2003), schizophrenia is best understood as arising from a disturbance or instability of minimal or basic self-hood, the sense of being present to (...) oneself and one's experiences (Henriksen, 2022). This disturbance appears as various experiential anomalies, sometimes termed "anomalous self (or world) experiences" or "self disorders," which include such phenomena as alienation from subjective processes, doubt in the existence of the world or one's own existence, fluidity of boundaries between self and others or self and world, and many other phenomena. Many of these have been captured in the Examination of Anomalous Self Experience (Parnas et al., 2005) and the Examination of Anomalous World Experience (Sass et al., 2017).At the same time, some research reveals the presence of self disorders in nonpsychotic conditions like panic disorder (Madeira et al., 2017) and depersonalization/derealization disorder (Sass et al., 2013). There are also competing phenomenological models that posit schizophrenia instead as a disturbance of dialogical self (Lysaker & Lysaker, 2002) or as a disruption of automatic perceptual processing (Uhlhaas & Mishara, 2007). Such works contain implicit critiques of the ipseity disturbance hypothesis that focus on the specificity of self disorders, or else on the specific nature of the underlying disturbance in schizophrenia.Wannberg's critique is distinct from these others: by considering the validity and function of recovery narratives, she raises crucial epistemological and ethical questions about the phenomenological approach to psychopathology, asking not only whose narrative counts, but how narrative counts. In particular, Wannberg questions a phenomenology that, she suggests, might find any ongoing symptoms as evidence of continued alterations of subjectivity, and that would then be dismissive of recovery narratives—a phenomenology that would prioritize the authority [End Page 71] of consciousness, as Wannberg puts it, over the authority of the person.It is worth stating here that the standard phenomenological response would not be to distrust or dismiss accounts of recovery. Ideally, phenomenological models, along with their ongoing theoretical developments and empirical work, are based on a deep respect for patients' experience and self-descriptions, striving to attend to experiences as they are lived without imposing pre-defined constructs that would limit or alter the experiences in a fundamental way (Nordgaard et al., 2013).Questions about the nature of recovery might be addressed within phenomenology by considering the difference between minimal (or basic) self and narrative (or extended) self, a more complex self-understanding or self-interpretation that is founded on the more basic, pre-reflective sense of being alive in the world (Gallagher, 2000; Parnas, 2007). According to proponents of the ipseity disturbance hypothesis, disturbances of basic self-hood can contribute to disturbances of narrative self, such as confusion about one's future goals or difficulties making sense of one's life history, though it is unlikely for disruptions that originate in the narrative self to trickle down to the minimal self (Henriksen, 2022). Such a view might similarly suggest that it would be unlikely for work on the level of the narrative self to lead to improvements in minimal self. Recovery, according to this approach, might best be viewed as an understanding of and compensation for alterations in basic self-hood, such that a person can develop a relatively solid narrative self that accounts for and manages disturbances of minimal self—while the minimal self may also grow more solid through various therapeutic interventions (Skodlar & Henriksen, 2019).Wannberg finds a more transformative possibility in Wittgenstein's grammatical approach, which is concerned with the function and rules of discourse. According to her grammar of recovery, recovery narratives are not only the product of a process of meaning-making and self-understanding, but they can create meaning and new realities. Furthermore, this process, according to Wannberg, has an inherently social and normative quality to it: the self-work that occurs in recovery and the recovery narrative involves the development of agency, autonomy, and responsibility in a social world... (shrink)

In a criminal trial, evidence is used to draw conclusions about what happened concerning a supposed crime. Traditionally, the three main approaches to modeling reasoning with evidence are argumentative, narrative and probabilistic approaches. Integrating these three approaches could arguably enhance the communication between an expert and a judge or jury. In previous work, techniques were proposed to represent narratives in a Bayesian network and to use narratives as a basis for systematizing the construction of a Bayesian network (...) for a legal case. In this paper, these techniques are combined to form a design method for constructing a Bayesian network based on narratives. This design method is evaluated by means of an extensive case study concerning the notorious Dutch case of the Anjum murders. (shrink)

This article provides empirical evidence of the social context and moral reasoning embedded within a parents’ decision to participate in autism genetics research. Based on in-depth interviews of parents who donated their family’s blood and medical information to an autism genetic database, three narratives of participation are analyzed, including the altruistic parent, the obligated parent, and the diagnostic parent. Although parents in this study were not generally concerned with bioethical principles such as autonomy and the issues of informed (...) consent and/or privacy and confidentiality of genetic information, a critical analysis reveals contextual bioethics embedded within these different narratives. These include the negotiations of responsibility that parents confront in biomedical research, the misguided hope and expectations parents place in genomic science, and the structural barriers of obtaining an autism diagnosis and educational services. Based on these findings, this article demonstrates the limits of a principle-based approach to bioethics and the emergent forms of biological citizenship that takes into account the social situations of people’s lives and the moral reasoning they negotiate when participating in autism genetic research. (shrink)

The increasing success of the evidence-based policy movement is raising the demand of empirically informed decision making. As arguably any policy decision happens under conditions of uncertainty, following our best available evidence to reduce the uncertainty seems a requirement of good decision making. However, not all the uncertainty faced by decision makers can be resolved by evidence. In this paper, we build on a philosophical analysis of uncertainty to identify the boundaries of scientific advice in policy (...) decision making. We start by introducing a distinction between empirical and non-empirical types of uncertainty, and we explore the role of two non-empirical uncertainties in the context of policy making. We argue that the authority of scientific advisors is limited to empirical uncertainty and cannot extend beyond it. While the appeal of evidence-based policy rests on a view of scientific advice as limited to empirical uncertainty, in practice there is a risk of over reliance on experts beyond the legitimate scope of their authority. We conclude by applying our framework to a real-world case of evidence-based policy, where experts have overstepped their boundaries by ignoring non-empirical types of uncertainty. (shrink)

Proponents of Evidence-based medicine (EBM) do not provide a clear role for basic science in therapeutic decision making. Of what they do say about basic science, most of it is negative. Basic science resides on the lower tiers of EBM's hierarchy of evidence. Therapeutic decisions, according to proponents of EBM, should be informed by evidence from randomised studies (and systematic reviews of randomised studies) rather than basic science. A framework of models explicates the links between the (...) mechanisms of basic science, experimental inquiry, and observed data. Relying on the framework of models I show that basic science often plays a role not only in specifying experiments, but also analysing and interpreting the data that is provided. Further, and contradicting what is implied in EBM's hierarchy of evidence, appeals to basic science are often required to apply clinical research to therapeutic questions. © 2010 Springer Science+Business Media B.V. (shrink)

A common method for warranting the historical adequacy of philosophical claims is that of relying on historical case studies. This paper addresses the question as to what evidential support historical case studies can provide to philosophical claims and doctrines. It argues that in order to assess the evidential functions of historical case studies, we first need to understand the methodology involved in producing them. To this end, an account of historical reconstruction that emphasizes the narrative character of historical accounts (...) and the theory-laden character of historical facts is introduced. The main conclusion of this paper is that historical case studies are able to provide philosophical claims with some evidential support, but that, due to theory-ladenness, their evidential import is restricted. (shrink)

This article analysed the Indonesian government’s strategy in eradicating terrorism and radicalism. This study was designed with quantitative methods within the framework of normative legal research using anti-terrorism-related regulations as the sample. Data analysis was carried out with content analysis to identify the conception of terrorism, radicalism and deradicalisation in the legislation. The research found that most of Indonesia’s counter-terrorism regulations associate terrorism with criminal actions. However, regulatory developments also present a decreasing association between terrorism and acts of violence alone (...) as terrorism is growingly being conceptualised by policymakers not only as a virulent action to an increasing extent but also ideologically based on the process of radicalisation. Consequently, various regulations after 2013 accommodate many prevention-based ideas and soft approaches. Newest regulations also accommodate deradicalisation as an important strategy in countering terrorism. This finding practically would imply including counter-narratives through education and deradicalisation strategies. It is also projected through counter-propaganda as a strategic deradicalisation approach. Its incorporation into regulations is needed as digital technology advances, making it easier for young people to be exposed to radical ideas through internet channels. Contribution: This study deepens empirical evidence regarding the need for an alternative soft approach strategy in dealing with religious doctrine-based radicalism. Apart from preventive measures through law enforcement which should be continuously strengthened, the findings in this research encourage preemptive methods in deradicalisation through counter-narrative, counter-propaganda and counter-ideology. (shrink)

Proponents of evidence-based policy (EBP) call for public policy to be informed by high-quality evidence from randomized controlled trials. This methodological preference aims to promote several epistemic values, e.g. rigor, unbiasedness, precision, and the ability to obtain causal conclusions. I argue that there is a trade-off between these epistemic values and several non-epistemic, moral and political values. This is because the evidence afforded by preferred EBP methods is differentially useful for pursuing different moral and political values. (...) I expand on how this challenges ideals of value-freedom and -neutrality in EBP, and offer suggestions for how EBP methodology might be revised. (shrink)

Complementary and alternative medicine has become an important section of healthcare. Its high level of acceptance among the general population represents a challenge to healthcare professionals of all disciplines and raises a host of ethical issues. This article is an attempt to explore some of the more obvious or practical ethical aspects of complementary and alternative medicine.

When is it justified to use opaque artificial intelligence (AI) output in medical decision-making? Consideration of this question is of central importance for the responsible use of opaque machine learning (ML) models, which have been shown to produce accurate and reliable diagnoses, prognoses, and treatment suggestions in medicine. In this article, I discuss the merits of two answers to the question. According to the Explanation View, clinicians must have access to an explanation of why an output was produced. According to (...) the Validation View, it is sufficient that the AI system has been validated using established standards for safety and reliability. I defend the Explanation View against two lines of criticism, and I argue that within the framework of evidence-based medicine mere validation seems insufficient for the use of AI output. I end by characterizing the epistemic responsibility of clinicians and point out how a mere AI output cannot in itself ground a practical conclusion about what to do. (shrink)

Recently, novel lines of research have developed to study the influence of identity processes in sport-related behaviours. Yet, whereas emotions in sport are the result of a complex psychosocial process, little attention has been paid to examining the mechanisms that underlie how group membership influences athletes’ emotional experiences. The present narrative review aims at complementing the comprehensive review produced by Rees et al. (2015) on social identity in sport by reporting specific work on identity-based emotions in sport. To (...) that end, we firstly overview the different terminology currently used in the field of emotions in groups to clarify the distinct nature of emotions that result from an individual’s social identity. Secondly, we discuss key concepts of social identity to better understand the mechanisms underlying identity-based emotions. Thirdly, we address existing knowledge on identity-based emotions in sport. We close the present narrative review by suggesting future research perspectives based on existing meta-theories of social identity. Evidence from the social psychology literature is discussed alongside existing works from the sport literature to propose a crucial theoretical approach to better understand emotions in sport. (shrink)

There exists a vast literature on evidence‐based practice in education. The debate branches out in several directions, for example, what EBP entails for the nature of educational practice, what it entails for the teaching profession, what counts as use and abuse of evidence, and what educational research could or should contribute to a what works kind of practice. In this essay Tone Kvernbekk focuses on the fate of the concept of evidence in the debate, observing that (...) the concept seems, by and large, to be missing from the debate. She argues that educational debates about EBP stand to gain in nuance and depth from employing philosophical insights about evidence. Kvernbekk develops this claim by discussing different conceptions of evidence and by inquiring into three aspects of the evidentiary relation: the meaning of “based,” underdetermination, and the relativization of evidence. (shrink)

The Evidence-Based Medicine (EBM) movement is an ideological force in health research and health policy which asks for allegiance to two types of methodological doctrine. The first is the highly quotable motherhood statement: for example, that we should make conscientious, explicit and judicious use of current best evidence (paraphrasing Sackett). The second type of doctrine, vastly more specific and in practice more important, is the detailed methodology of design and analysis of experiments. This type of detailed methodological (...) doctrine tends to be simplified by commentators but followed to the letter by practitioners. A number of interestingly dumb claims have become entrenched in prominent versions of these more specific methodological doctrines. I look at just a couple of example claims, namely: Any randomised controlled trial (RCT) gives us better evidence than any other study. Confidence intervals are always useful summaries of at least part of the evidence an experiment gives us about a hypothesis. To offer a positive doctrine which might move us past the current conflict of micro-theories of evidence, I propose a mild methodological pluralism: in any local context in which none of a variety of scientific methodologies is clearly and uncontentiously right, researchers should not be discouraged from using any methodology for which they can provide a good argument. (shrink)

ObjectsHealth Behaviours in School-aged Children is an international survey programme aiming to investigate adolescents’ health behaviours, subjective perception of health status, wellbeing, and the related contextual information. Our scoping review aimed to synthesise the evidence from HBSC about the relationship between family environmental contributors and adolescents’ health-related outcomes.MethodsWe searched previous studies from six electronic databases. Two researchers identified the qualified publications independently by abstract and full-text screening with the assistance of an NLP-based AI instrument, ASReview. Publications were included (...) if they were based on HBSC data and investigated the effects of family environment on adolescents’ health outcomes. Researches addressed family-related factors as mediators or moderators were also included.ResultsA total of 241 articles were included. Family environmental contributors could be mapped into six categories: Demographic backgrounds ; General family’s psycho-socio functions ; Parenting behaviours ; Parental health behaviours ; Family activities ; and Siblings. Except for 75 papers that assessed family variables as moderators and mediators, the others suggested family environment was an independent variable. Only five studies employed the data-driven approach.ConclusionOur results suggest most research studies focussed on the influences of family demographic backgrounds on adolescents’ health. The researches related to parental health behaviours and siblings are most inadequate. Besides, we recommend further research studies to focus on the mediator/moderator roles of the family, for exploring the deep mechanism of the family’s impacts. Also, it would be valuable to consider data-driven analysis more in the future, as HBSC has mass variables and data. (shrink)

This thesis examines philosophical controversies surrounding the evaluation of medical treatments, with a focus on the evidential roles of randomised trials and mechanisms in Evidence-Based Medicine. Current 'best practice' usually involves excluding non-randomised trial evidence from systematic reviews in cases where randomised trials are available for inclusion in the reviews. The first paper challenges this practice and evaluates whether adding of evidence from non-randomised trials might improve the quality and precision of some systematic reviews. The second (...) paper compares the alleged methodological benefits of randomised trials over observational studies for investigating treatment benefits. It suggests that claims about the superiority of well-conducted randomised controlled trials over well-conducted observational studies are justified, especially when results from the two methods are contradictory. The third paper argues that postulating the unpredictability paradox in systematic reviews when no detectable empirical differences can be found requires further justification. The fourth paper examines the problem of absence causation in the context of explaining causal mechanisms and argues that a recent solution is incomplete and requires further justification. Solving the problem by describing absences as causes of 'mechanism failure' fails to take into account the effects of absences that lead to vacillating levels of mechanism functionality. The fifth paper criticises literature that has emphasised functioning versus 'broken' or 'non-functioning' mechanisms emphasising that many diseases result from increased or decreased mechanism function, rather than complete loss of function. Mechanistic explanations must account for differences in the effectiveness of performed functions, yet current philosophical mechanistic explanations do not achieve this. The last paper argues that the standard of evidence embodied in the ICE theory of technological function is too permissive for evaluating whether the proposed functions of medical technologies have been adequately assessed and correctly ascribed. It argues that high-quality evidence from clinical studies is necessary to justify functional ascriptions to health care technologies. (shrink)

Even though the evidence‐based medicine movement (EBM) labels mechanisms a low quality form of evidence, consideration of the mechanisms on which medicine relies, and the distinct roles that mechanisms might play in clinical practice, offers a number of insights into EBM itself. In this paper, I examine the connections between EBM and mechanisms from several angles. I diagnose what went wrong in two examples where mechanistic reasoning failed to generate accurate predictions for how a dysfunctional mechanism would (...) respond to intervention. I then use these examples to explain why we should expect this kind of mechanistic reasoning to fail in systematic ways, by situating these failures in terms of evolved complexity of the causal system(s) in question. I argue that there is still a different role in which mechanisms continue to figure as evidence in EBM: namely, in guiding the application of population‐level recommendations to individual patients. Thus, even though the evidence‐based movement rejects one role in which mechanistic reasoning serves as evidence, there are other evidentiary roles for mechanistic reasoning. This renders plausible the claims of some critics of evidencebased medicine who point to the ineliminable role of clinical experience. Clearly specifying the ways in which mechanisms and mechanistic reasoning can be involved in clinical practice frames the discussion about EBM and clinical experience in more fruitful terms. (shrink)

Evidence-based medicine (EBM) has long deemphasized mechanistic reasoning and pathophysiological rationale in assessing the effectiveness of interventions. The EBM+ movement has challenged this stance, arguing that evidence of mechanisms and comparative studies should both be seen as necessary and complementary. Advocates of EBM+ provide a combination of theoretical arguments and examples of mechanistic reasoning in medical research. However, EBM+ proponents have not provided recent examples of how downplaying mechanistic reasoning resulted in worse medical results than would have (...) occurred otherwise. Such examples are necessary to make the case that EBM+ responds to a problem in clinical practice that urgently demands a solution. In light of this, we examine the failed rollout of efavirenz as a first-line HIV treatment in Zimbabwe as evidence of the importance of mechanistic reasoning in improving clinical practice and public health policy decisions. We suggest that this case is analogous to examples commonly given to support EBM. (shrink)