L’evidence-based medicine, un projet épistémologique et éthique en porte-à-faux avec la psychiatrie ?

Current mainstream psychiatric discourse and practice rely mostly on a dominant technological paradigm where mental distress is understood as a "faulty mechanism" which needs "fixing" through medical means. As such, evidence-based medicine (EBM), a recent medical concept which encourages technological knowledge and hence technological understanding and interventions, was embraced by contemporary psychiatry. EBM is a proposition which seeks to regulate clinical decision-making by putting forth the idea of a hierarchy of evidence, where information yielded from randomized controlled trials (RCTs) and meta-analyses have definite precedence over other forms or sources of information. Thus, because EBM favors these evidence-producing tools, RCTs and meta-analyses, it purports that the knowledge that counts is that which is measurable and specific; necessary conditions for its detection by such tools. In doing so, EBM devalues and arguably even ignores other forms of evidence and warrants for clinical decision-making. From the standpoint of ethics, it purports that the "right" thing to do is to apply the evidence produced by EBM in a clinical setting. Other forms of evidence and relevant information regarding clinical decision-making which cannot be produced or measured by EBM are ethically devalued. Reviewed literature in the field of philosophy of psychiatry thus argues that EBM is ill-suited for psychiatry. It has a reductive view of the epistemological and related ethical issues regarding psychiatric practice. It cannot, by design, account for the specificities of psychiatry, notably in terms of diagnoses; their complexity easily renders the evidence created by EBM of questionable validity. It also cannot account for the specificities of psychiatric therapeutics. Outcomes related to the mind are incorrectly translated into specific and measurable results, and amongst other points, non-specific therapeutic factors, the ones discredited by EBM, are core to mental health care: nonsense. This leads the current critical review to consider that psychiatry would perhaps benefit from the development of its own evidentiary framework, taking into account its unique epistemological position, where subjectivity, context and values cannot be downplayed in the hierarchy of evidence, in the hierarchy of warrants for decision-making. This discussion inevitably raises the question of the object of study of psychiatry, which appears to be somewhat different than that of medicine. It also forces a conversation on the goals of psychiatry; they appear more complex than the achievement of measurable and specific health outcomes. Although a definite alternative to EBM in psychiatry has yet to be established, the literature, and this paper, point towards the idea of a more flexible evidentiary framework for psychiatry, one where ethical issues, including the ethics of what counts as evidence, should be of crucial importance.

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