Evidence-based medicine and power shifts in health care systems

Abstract

Over the past two decades, Evidence-based Medicine has attracted more and more attention in the medical community. Local, regional, national and international networks of clinical review groups have evolved. One is the Cochrane Collaboration, which produces, maintains and disseminates systematic reviews of the evidence about the prevention and treatment of health problems. The Cochrane Collaboration operates on such an international scale, that it has been conceived of as "an enterprise that rivals the Human Genome Project in its potential implications for modern medicine" (Naylor, derived from Muir Gray 1997 P 223). What is the reason for considering power shifts in health care systems from the perspective of Evidence-based Medicine, as discussed by Biller-Andorno, Lie and Ter Meulen? A natural response would be to state that Evidence-based Medicine deals with (scientific) evidence and nothing but evidence. The accumulated body of medical evidence is necessary to support diagnostic and medical interventions by physicians. At best, one could say that Evidence-based Medicine is advocated to counterbalance societal power, be it from patients and patient groups, insurance companies, governments, or other parties involved in health care. How could one object to the ambition and endeavour of proponents of Evidence-based Medicine to critically assess scientific evidence to support decisions in medicine and health care? What, if anything, could be wrong with doing the right things right as Muir Gray (1997) formulates the new management agenda of evidence-based health care? There is, however, an interesting way to question the relationship between Evidence-based Medicine and power shifts in health care systems. Although definitions of EBM are phrased as a scientific approach to medicine (Sackett et al. 1996; Muir Gray 1997; Offringa et al. 2000), EBM is a normative concept. The concept of EBM aims to improve medicine and health care, that is, it encompasses a view on five issues: the best source of medical evidence, the best method to gain medical evidence, the best medical result to be achieved, the best expert to make medical decisions and the social function of medicine? Regarding the last issue, Sackett and his colleagues (1996) argued that EBM is concerned with making evidence-based clinical decisions in the care of individual patients. Other proponents of EBM, however, have extended the range of EBM to evidence-based health care (EBHC): "In the 21st century, the health care decision-maker, that is, anyone who makes decisions about groups of patients or populations, will have to practice evidence-based decision-making" (Muir Gray 1997 P 1). Within the scope of this paper, it is not possible to analyse the pros and cons of the various definitions and interpretations provided either by proponents or opponents of EBM. Our contention is that both proponents and opponents use normative concepts on the five issues identified above. More particularly, they provide particular views on positions, responsibilities, possibilities, norms and relationships between professionals, patient groups, governments and other parties in health care and society. From this perspective, we will analyse the role of EBM in modern western societies. The power concept we want to employ is a Foucauldian one, based on the assumption that power effects are at the very core of the production and distribution of knowledge in the human sciences (Foucault 2000). Foucault has analysed this type of knowledge in terms of discursive systems, including ways of ordering human activities and defining human characteristics, especially subjectivity. Thinking of knowledge and power in terms of discursive systems enables us to focus on the distribution of roles and responsibilities between the various actors involved in the arena of EBM and health care. We amend this Foucauldian line of thinking with a normative perspective from citizenship theory, arguing that the role of EBM is not fixed, but depends on the relationship between state and society. We will first analyse the fundamental change in western societies during the past decades, from modern to post-modern societies. Then, we wifi present a fourfold model of possible relationships between state and society and discuss how EBM may fit in, by giving some examples of the practice of EBM in different European countries. Lastly, we propose to consider EBM as a public forum where proponents and opponents of EBM discuss diverse and possibly conflicting ways of changing medicine, health care, and health policy. © 2005 Springer-Verlag Berlin Heidelberg.