https://unbekoming.substack.com/p/ebm-evidence-biased-medicine

The 1992 Inversion

In November 1992, the Journal of the American Medical Association published a paper titled “Evidence-Based Medicine: A New Approach to Teaching the Practice of Medicine.”¹ The authors, the Evidence-Based Medicine Working Group at McMaster University, led by Gordon Guyatt, announced a paradigm shift. The first paragraph named what was being replaced: “intuition, unsystematic clinical experience, and pathophysiologic rationale.”¹ The replacement was a hierarchy in which the randomised controlled trial sat at the top and clinical observation sat near the bottom.

The paper was not modest. It described its proposal in Kuhnian terms and predicted that the old approach — the physician’s accumulated judgement, the recognition of patterns across thousands of patients, the reasoning from mechanism and first principles — would be superseded.¹ Within a decade, the framework had been adopted across major medical journals, accreditation bodies, and clinical guideline organisations. In a 2007 BMJ poll of more than 11,000 readers asked to name the most important medical milestones since 1840, the sanitary revolution placed first, antibiotics second, anaesthesia third; evidence-based medicine appeared on the shortlist of fifteen.²

What was elevated to the top of the hierarchy was the one form of evidence pharmaceutical companies could afford to manufacture at scale. What was demoted to the bottom was everything they could not control. This was not the discovery of how medicine should be practised. It was the redefinition of what counted as knowing. The framework called itself evidence-based. What it actually was, was evidence-biased — a hierarchy in which what counted as evidence was determined, first, by who could afford to produce it.

The essay examines what that redefinition did, who it served, and the cost in lives. Ctd....