Continuing the evidence‐based health care debate in 2006. The progress and price of EBM

In Volume 12, Part 3 of the Journal of Evaluation in Clinical Practice, we committed to the international medical literature a deposit of considerable scholarship on the evolution of the evidence-based medicine (EBM) debate and on the nature of evidence for clinical practice (Borry et al. 2006; Couto 2006; Dewhurst 2006; Djulbegovic 2006; Dobre et al. 2006; Geanellos & Wilson 2006; Gupta 2006; Leung & Johnston 2006; Lipman 2006; Loughlin 2006a,b; Kemm 2006; Maier 2006; Malterud 2006; Miettinen 2006; Miles et al. 2006, Porta 2006; Roddy et al. 2006; Sandars & Heller 2006; Stevenson et al. 2006; Tanenbaum 2006; Tonelli 2006; Upshur 2006a; Upton & Upton 2006). In the current issue, Volume 12, Part 4, we publish those articles that for practical reasons of space could not be included in Volume 12, Part 3, but where editorially judged urgency of publication precludes their being delayed until the 10th thematic edition on EBM in early 2007. This Part II of the ninth thematic edition on the progress of the EBM movement therefore augments Part I (Miles et al. 2006) and the previous eight (see Miles et al. 1997, 1998, 1999, 2000, 2001, 2002, 2003, 2004). This opus having now been achieved, we again invite contributions to the 10th thematic edition for publication in 2007. Recurrent themes in the contributions to this and previous thematic editions concern the apparent failure on the part of many advocates of EBM to explain and justify their most fundamental assumptions – about the nature of science, rationality and evidence itself, and how these key concepts may be put to work in the formulation of any defensible view about proper medical practice. We believe that it is necessary for any intellectually serious analysis of the phenomena associated with EBM to explore and, if possible, attempt an explanation of this surprising omission on the part of defenders of so influential and pervasive a doctrine. Even the attempt to characterize EBM as a ‘doctrine’ may be challenged (Lipman 2006), but this difficulty in finding any consensus about what EBM is can itself be seen as one of the more puzzling of the phenomena crying out for explanation (Loughlin 2006c). Any author attempting such an analysis must be driven to consider not only contributions to the EBM literature, but also the processes that produce that literature – he must effectively take the debate itself as the object of his study and ask causal questions about how it comes to take the form it does. What forces drive the debate about EBM? What assumptions or interests give rise to or frame that debate? Why are some questions regarded as apparently unworthy of serious consideration and banished to the margins of debate by organs that (by general consensus) may be regarded as defining the ‘mainstream’ in medical discourse? To address these questions, it will be necessary to consider the processes which affect publication practices in certain influential medical journals. In this context, it is therefore appropriate for us to discuss openly the processes which led to the publication of the first two papers in the current issue. One of these (Upshur et al. 2006) poses in our view a necessary and, it would certainly seem, overdue question: ‘Can scholarly journals be in financial conflict of interest situations?’ Readers might imagine such a question to be purely theoretical, even somewhat ludicrous, given the level of trust built up over long years by periodicals of international stature. Recent events at the Journal of the American Medical Association, at the Canadian Medical Association Journal and elsewhere begin, however, to make questions relating to conflicts of interest in general, more than topical and essential to pose. In order to explain the Editor’s rationale in commissioning and publishing such a paper, we would invite the reader to study, firstly, the juxtaposed paper contributed by Buetow et al. (2006). It is now possible to document here that the substance of that particular article (Buetow et al. 2006) was written, initially and relatively speedily, for publication in the British Medical Journal (BMJ), following that journal’s decision to take, intentionally or inadvertently, the same position as the Journal of Evaluation in Clinical Practice (JECP) in publishing a thematic edition on EBM (Straus 2004). But while the JECP has been noted for its impartiality and objectivity in publishing both so-called ‘pro-EBM’ as well as ‘anti-EBM’ articles, thus following the classical intellectual tradition, the thematic edition of the BMJ was characterized principally by its dramatically ‘pro-EBM’ stance. Not believing that the BMJ could possibly simply be paying ‘lip service’ in inviting responses to its thematic edition, the authors (Buetow et al. 2006) submitted their article only to see it very swiftly rejected, despite the fact that it had directly addressed – and contested in lucid intellectual terms – many of the precepts and approbations of EBM that the BMJ had appeared selectively to favour for publication in its thematic edition. Indeed, the thematic edition of the BMJ had published an extensive number of so-called ‘pro-EBM’ views, while the only article expressing ‘concerns’ about the whole conceptual and practical basis of EBM had been relegated to the back of the BMJ and branded under the extraordinary heading Personal View. Buetow et al. (2006) subsequently contested the rejection of their article by the BMJ, understandably requiring, in these days of ‘transparency’ and ‘accountability’ (concepts, it must be noted, that the BMJ itself has seen fit to pioneer), a proper and fully rational account of the basis on which their article had been rejected. ‘Lack of originality’ was the reason given, yet the article had raised a considerable number of objections to the concept and practice of EBM that had not been considered by any of the articles selected for publication in the thematic edition of the BMJ on EBM. The reason for rejection given was therefore not accepted by Buetow et al., who it for the reasons we that the rejection of their article may been the of nature of which we to Buetow et al. (2006) their objections to the of the BMJ by of such is to a decision on such The authors not surprising the decision of the BMJ that the The is not an in the EBM and therefore is not to make a on the intellectual of EBM but effectively an of the BMJ with a to proper the processes of as are and us here a the processes of what is accepted as and and the of such of who in the of intellectual progress that a for such progress is and This the of being – and even being to a in the for a one the in terms of consideration of both and if a is to be or in terms of of and as only and of in any we take our to be and Indeed, if any to the EBM debate that in this is and that the debate has been we invite to us in and terms the and of its intellectual we evidence in the literature of any such as having at the of is evidence that progress is where is We therefore it as essential that journals not in their publishing it us as for an to and a position on a and we see in their to the of the must be given its journals are the in which such debate and this is it is so that not the of any given are the intellectual which must not be by any interests – be or This is the fundamental the of publishing and it is our reason for commissioning on papers published in these and inviting the authors of papers to to where authors to the that to be to in a this in our be of a of intellectual (Loughlin To such it is necessary to be possible or of the It is that certain will who are or can be to given of a paper or and if those are at to those to in the of their on the paper or can to than at the Journal of Evaluation in Clinical Practice, by the of the rejection by the BMJ of Buetow et paper and been to the in the necessary we and contributed an article which out to on the This us to the paper in this Part II of the thematic edition on EBM 2006, the article by Upshur et al. (2006). In that paper, the is that some medical journals may in a financial conflict of interest In order to what might be of on which more study might be the authors the of financial that BMJ for many years until very by the British Medical Association is the BMJ the of a very extensive of ‘pro-EBM’ and journals. Indeed, the BMJ to its to the of the and we to financial the of ‘pro-EBM’ The authors that scholarly journals can in conflict of interest which for reasons may the publication of articles which question the of the being the authors the that the more extensive the and the the the is the for conflict of is the nature of the by Upshur et al. and considered in this we on the part of or a we explain our some will to us this and our by its Lipman (2006) that EBM be an for reasons which the fact that it was not by a of We with Lipman that EBM was not the of any such to such phenomena as apparent in publication and the general of the debate about we a of more in its to the work of than that of This not that EBM be as a of it that such a of EBM can in for the of the EBM to the extensive literature on how an can be any to this Upshur et al. the basis for what we will an conflict of how can be to financial and interests any of or and the that the current of EBM is an of a rise to and financial conflicts of Indeed, the authors that it would be in the to that journals are to processes and that are to affect published are many of the terms and in and literature, and it would be for us to any one of the One of the in the of the current debate is as To that a debate has is to that the to it assumptions of a fundamental nature which affect the that the under (Loughlin To that is the an or is in fact an is to that he is or to his fundamental assumptions to The his assumptions as to any explanation or To such a the very fact that with even simply his view is evidence that the has not (Loughlin This analysis has been in the explanation of the in – a with the of in many (Loughlin that with the of practice by a The of these had to with the fact that the and interests of certain and the of the also to the of its defining – for as defenders are of one can be to this the for was to the of in of any analysis of the of any or evidence that the addressed those It the interests of to be as to that are at and the movement the that its with a that to in the of the that this any of the nature of as many of its the more such and the more in the and of in this the more it to many that the movement an of such that the of its assumptions to to In some the has so ‘mainstream’ that the attempt to question it its defenders as or such that to so is to be of with the of (Loughlin In this has an a of in or which us to view the in a certain and to – with and is the even to question its it is as an of This to the interests of many the authors of the many and to and the of work or the and of such we can see how a or of interests can a as the interests the more and the the for literature how to such in and the more will be to days and events to with these if any of these of will as to a but will see the for as to a serious The of the and the or of the the driven by the to to the of the the the and the intellectual to about how to the of the not to those to We believe that a very has the extraordinary of EBM. one is to of EBM and clinical evidence with evidence certain the movement the that its with a that to 2006), yet many by the nature of the fundamental Porta the of interests that has what to be an so as to be question – that medicine be on it is the that can to a the which are and to and in a that to the and EBM the basis for to a and are but very are to the and more But the to on will on more will to be in more and so of been built on of in an and see how a has in which EBM and its following of and clinical to a and in 2006) the on the part of its defenders that fundamental EBM has the of to be associated with an that to a at and with EBM has been as a of & with the we seen that of EBM are not even to consider the that about their might be Indeed, we noted their of and their to in and in such a position as both and The of the of EBM to in scholarly debate two to to published articles which and with fundamental for to their the published of their in their one of the and most of for an extraordinary and a in the of clinical he is if by the of an one that one of the of EBM is to for and It is the nature of the of EBM that would see the work of and that of many published in the Journal of Evaluation in Clinical Practice, as EBM are to and to those of their et al. such are if at as to the that are or or as to an We at a in intellectual of can be not been but those with the to and or work for that the in which are or in some the these as simply to our (Loughlin We to be a more about this than many current to The be with to the interests of any or a debate or of to be by such this its as a for at the In a where the of evidence and the are we must be in the an for the and a the current for EBM has led us to in the of journals (Upshur et al. 2006), the of some for the of EBM not its in practice as and publishing which in the and in the and the is it is that such dramatically We are some scholarly journals so in the of the EBM as to their as for debate? forces to the intellectual questions be and certainly not in the of an and such questions can be only raised at this the of we are the that it has been possible to the that may be on and the to for more study of the that are both here and in some of the papers of this issue. the reader may to on what has been and here in to the and financial basis of the EBM The reader is to the Editor’s on In the paper of this Part II thematic edition on we to a that of the of In his of – or (2006) that in the EBM has and we that EBM has and has had we not that it has and it has most certainly not despite its very questions we this or the and of EBM is only to view medicine in the and and extensive EBM with may be the to in order and of these questions and in (2006) the concept of which he to with as an that might be the of medical and decision in order to more we two on his article and publish these following In the first of Upshur on the concept of which this author of to his given the the EBM movement and the so-called Indeed, he the of literature the and of despite the fact that EBM has itself and thus of its of he its or to address the of serious intellectual and clinical that been finding of interest in Upshur this work as of the the EBM Indeed, the author that is now of for a view of what EBM is or is not and, as a we a of many of what EBM may Upshur these are by are the of EBM? for Upshur the difficulty as it to of he is to that has The (Loughlin up on of and in the of his key terms and in the nature of the being The out the to work on EBM and work on in that EBM is the to in medicine and and that its is more than But having these the author by questions as to what EBM is and what the of EBM by can that we EBM as one of the to we if it and how it is it that he can on to ask – having that EBM is one of the to medicine – our more the EBM than its and our EBM than those under any The to be that while EBM is it is by certain what EBM is – a somewhat puzzling work may be seen to an of the processes considered in the first part of this is to serious questions about EBM. to or and to being or in his he to questions about the of EBM with an of its has in where of for EBM is to out a as of and in any intellectual so effectively by one must by paying to the as the of to the even one to on to question these in some to not in the intellectual this the paper a of apparent or even the (Loughlin that it is that an can even by those to questions about and to take a on the fundamental questions his paper to is a in in the article by (2006). This the of of the of out that might be on the nature of the the to the and the under the the of clinical in the of the a and on the nature of evidence for clinical practice. is that medicine is not and has an science, that medicine therefore on on clinical Indeed, he of those who would with to his (2006) by the view that is necessary to that EBM to be and extensive an and to its that this can be that practice of EBM is up the to the and and in to the same and to a EBM to 2006). It is for this reason that we this paper with that of in order to the nature of a of on the EBM debate to which can characterized by a lucid of the and of the EBM while the to would be if EBM and therefore it a so we can some authors the that one be to EBM more than one could be is pervasive it is seen to be in even in the of those attempting to question or This the to which many are the EBM and the that if we are simply to on these of what Upshur and Loughlin in the article by (2006) can therefore be to the of the paper by (2006). We to two contributions In these most the author that the debate on EBM is the of an that and in and a EBM is to with to its to and and therefore in its to a and he on to how certain of such a may be We in the of this to papers which are with of and evidence for clinical practice. In the first paper, & (2006) are to discuss the of which believe to be a in evidence the of questions by such as will with the of and where the which may be as been to of which at the of the with following and & (2006) such the so-called of evidence on the basis of with being as a concern which is considered the evidence and therefore to the to consider than being in to the of the to an of the nature of and and the nature of both the and of for clinical their view that current would be if considered evidence in these two to the position where only by evidence with and evidence with selected as appropriate for clinical practice. out that these would for in in and in the general of of the where are most these authors are that give the of can be addressed with In this context, us that the very of the study of clinical with the to on this consideration of and of and its for clinical we to et article on and as key in and the clinical of et al. 2006). The authors the on as being not only in the of such being published in the literature, but also in what as the and which but is by the of the and such as Clinical and so this in et al. (2006) out the of the consideration of Indeed, that of relating to the of and publication of the selected for but it is not at for such to for the of and on the of the to current clinical practice. It is and that the authors consider in their paper, to that is a key that is not but be the of the as a of of as being the formulation of the the of for and of the of and the of the clinical of the of the that will be and the of the of the are and We with et al. the for authors of to publication of such as a of the of a and its publication as a of This consideration is of one that most the practice that are and therefore of by the in the The paper of this a clinical practice and of et al. the of under and the of those to may be these authors are fundamental the and of and the in the that will Indeed, in the of the given is in an clinical and with the of with the and the is (by by and therefore in to where the of a of and In order to explore the of these on the of et al. (2006) a with the clinical by a study and a with for the of in the of with clinical was to be a of the directly the explanation of the in in previous some of which on assumptions and some of which on an We are thus to Part I and Part II of the on EBM of the Journal of Evaluation in Clinical Practice, by that or or decision or or or or are on conceptual and so-called and to practice which with their of Indeed, of the of intellectual by the so-called (see Loughlin a of can be by such and is both and and directly of how and the of the Indeed, to the in Part I of this thematic edition (Miles et al. 2006) of the of the the the reader may be we to that the BMJ has the concept of 2006). Indeed, while this and to our on the of the the reader may be by that the BMJ the and of this concept and practice with to a study on and its with in and Indeed, the to us that in a to of and of the of their while in both that this particular their concept and and one most following its for we to the of of its nature and We with (2006) that medicine is not a in the same as for where which is not Indeed, as medicine is the of where the of and the more make such an and rationality the of where has been to a but is that will what will in with his of financial and 2006). is that EBM to the of medicine an but that what and to medical will be an the space by the of and on is that is the than the of and that it is a an a practical particular of it to be that a of the of medicine as is a fundamental such to be by the EBM as part of their it is that fundamental which we that questions in clinical medicine are in the by EBM and therefore be by as it (Miles et al. even in the of its and as a which is not a but an which et al. et al. 2006; 2006). the nature of clinical practice being thus as both and it to and medicine with proper to both and not simply to one or the The of as is therefore an which to the defining of what it is to be a We our and so that to to and medicine with to a more than a that and clinical and which its in the of to be in such – and the that it – and well to to consider a of of clinical in the of their We our view that the is not as as part of but medicine (see Malterud 2001, 2002, 2006; Miettinen and we to the of the 10th thematic edition on EBM which will as its basis a and analysis of this In the to Part I of this thematic edition on EBM (Miles et al. 2006), we in Part we would explore the of financial and conflicts of interest to the concept and practice of EBM and that two of the articles to in the and now Part II of the JECP (Buetow et al. 2006, Upshur et al. 2006) would questions about the interests that may give rise to in publication practices in and medical journals. we to we that the most of the BMJ an article & 2006) and an 2006) on the of conflicts of interest and in medical published to our We to discuss conflict of interest to our by of EBM of the or not our was causal or has been in this we are to at the of to this we to make any to the current Part II thematic of the we that the analysis and the associated is by the in the articles in the Indeed, we are that our to this has been so swiftly by the publication of these articles and conflict of interest and we to the and of that we this will The to Buetow for the omission of his on Tonelli (2006) Volume article is included in the current part (Buetow 2006,

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