What Evidence? Reflections on Better Evidence for Better Healthcare

by Rani Lill Anjum, Better Evidence for Better Healthcare Manifesto

CauseHealth offers a new ontological foundation for medicine, what we call Causal Dispositionalism (Mumford and Anjum 2011). From this perspective, better evidence would mean evidence of causation, understood as something tendential and intrinsic. Specifically, better evidence of causation would involve theoretical understanding of how and why an intervention brings about a certain effect. But we should try to develop this understanding to also include how various factors interact, for instance, what could counteract the effect, what could enforce it and what else is causally relevant for the outcome. (more…)

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Better Evidence for Better Healthcare Manifesto: the CauseHealth Perspective.

The “Better Evidence for Better Healthcare Manifesto” initiative was recently launched by the Oxford Centre for Evidence Based Medicine (CEBM) in collaboration with the British Medical Journal (BMJ).

The manifesto is motivated by a series of problems and blind spots in the implementation of EBM: lack of high quality evidence, systematic research errors, under-reporting of harm, insufficient inclusion of patient’s priorities are some of the issues named by the Manifesto’s promoters. The purpose of the initiative is to spot what could be changed and how, in order to improve the current situation. (more…)

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Evidence synthesis in pharmacology

By Elena Rocca

Pharmacology is a complex science that aims to balance harm and benefit of treatments for the individual patient. How should different types of evidence be synthesised in order to optimize this task? Should evidence from randomized trials be prioritized over other evidence, following the EBM model? If not, how can different types of evidence be amalgamated in an alternative way? (more…)

What is the form of causation in health and disease, and intervention?

By David Evans

In a paper with a very long title, recently published in Medicine Health Care and Philosophy, Roger Kerry, Nic Lucas and I set out some ideas about how causation applies to relationships between health and disease. In particular, we focused on how treatment (intervention) might act to limit disease and restore health. (more…)

Analogies and High-Stakes Inferences

Samantha Copeland, Thinking about guidelines:

I have been interested for a while in how we justify the move from a single case to conducting research on other patients as research participants. For instance, there have been cases where unexpected (positive) results suggest that a novel approach to treating difficult patients may be found: such as the case in Toronto, Canada where electronic stimulation of a patient’s brain had an effect on his memory that suggested a new method for treating Alzheimer’s might be available; or in Bergen, Norway, when a patient with chronic fatigue unexpectedly recovered from her symptoms while undergoing treatment for Hodgkin’s disease. When a decision is made to start research, researchers must justify why they think the observations made of this particular patient could be repeated in others.

I believe this justification process is most simply expressed as an analogy: one argues that this particular patient is like some other patients in the right ways, and so we can reason that the same effects can be caused by the same treatment approaches. Therefore, it is both correct and ethical for research to attempt to recreate the same results by doing the same things to research participants as was done in this one case with this one patient. (more…)

Standards for Regulation

Stephen Tyreman, Thinking about guidelines:

Following on from the stimulating and highly relevant discussion about guidelines, I want to raise the point that there is a political dimension to the guidelines question that can’t be ignored if the CauseHealth project is to have practical relevance.  I recognise that the previous discussion was around clinical guidelines such as those produced by NICE, but these cannot be divorced from the broader issue of guidelines as they concern professional regulation. (more…)

Challenging Multi-Morbidity

Anna Luise Kirkengen, Thinking about guidelines:

I would like to depart from the most common situation in General Practice, namely: encounters with patients who are categorised as presenting multi-morbidity. This is how it is expressed in the medical language. I would try to change this formulation to something like: a GP’s encounter with a person suffering from what medicine conceptualises as a “number of different diseases”, either simultaneously or sequentially, in the same patient. The concept of “different” diseases does not apply when states of bad health are not strictly separable in terms of etiology, pathogenesis, treatment, and prognosis. Then the question is: on which level does medicine differentiate ethology or pathogenesis. If “two” diseases have a pathological characteristic in common, let us say inflammation, are these “two” diseases still “different” — and due to which criteria? The inflammatory process may affect neuronal cells in one case and connective tissue in the other. This leads to different symptoms and impairments, but both states of illness can be “treated”, in the sense of slowed down or even blocked (though not healed), by the same chemical, namely Cortison, a substance counteracting inflammation — but, in the healthy body — also ignating inflammation. Now —  as inflammation is the pathological property underlying “both types” of diseases, is inflammation to be regarded as CAUSAL? The next question is: what causes the physiological complex termed inflammation? In an evolutionary perspective it is the organisms response to being hurt, being traumatized. Next: does this connection strictly apply to acute, physical wounds/trauma alone? No, we have solid evidence that also experiential hurt or trauma can “cause” inflammation. Is this kind of causal relationship different from the other? …….

and so on and so on.

The nexus of multi-morbidity (as a medical construct or even artefact), causality (as to “level” of origin) and guidelines (specifically designed for each disease) is theoretically highly challenging yet the most common clinical reality in General Practice.