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Brief Treatment and Crisis Intervention 4:197-204 (2004)
Brief Treatment and Crisis Intervention Vol. 4 No. 3, © Oxford University Press 2004; all rights reserved.

Legitimacy, Authority, and Hierarchy: Critical Challenges for Evidence-Based Medicine

   Ross E. G. Upshur, MD, MSc, FRCPC
   C. Shawn Tracy, BSc

From the Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.

Contact author: Ross E. G. Upshur, Primary Care Research Unit, Sunnybrook and Women's College Health Sciences Centre, 2075 Bayview Avenue, #E 349, Toronto, Ontario, Canada M4N 3M5. E-mail: rupshur{at}idirect.com.

This paper examines four challenges that proponents of evidence-based medicine (EBM) must address to establish its claims to universality and legitimacy. It is argued that the failures to meet the evidence-of-effectiveness challenge, the authority challenge, the conflicting hierarchy challenge, and the definition-of-evidence challenge diminish arguments for the superiority of EBM. In the second part of the essay, recent developments in the theory of EBM are discussed with specific reference to what is termed the Oslerian turn, and a relationship between EBM and rationality is entertained.

KEY WORDS: evidence-based medicine, clinical reasoning, decision making, patient problems






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