Accounting for EBM: notions of evidence in medicine

This paper takes as a focus of anthropological enquiry the set of techniques and practices for the appraisal and clinical application of research evidence that has become known as evidence-based medicine (EBM) (or, more recently, evidence-based health care). It first delineates and classifies the criticisms of EBM emerging from within the health professions. It then charts the evolution of EBM in responding to these criticisms and uncovers its character as a pedagogical innovation aimed at transforming clinical practice. It identifies EBM as an indeterminate and malleable range of techniques and practices characterised not by particular kinds of methodological rigour, but by the pursuit of a new approach to medical knowledge and authority. It situates this characterisation within a contemporaneous political and economic climate of declining trust and growing accountability. This analysis provides a basis from which to consider the notions of evidence implicit in EBM itself and also in the qualitative social sciences, including anthropology, which not only critique but also contribute to these notions themselves. Finally, the paper considers possible future trajectories for EBM with regard to the incorporation of cultural and structural dimensions of health and the inclusion of qualitative material in the evidence base.