The politics of evidence-based medicine.

The impetus for these essays on evidence in medicine and law is commonly called evidence-based medicine: the movement to evaluate the safety, effectiveness, and cost of medical practices using tools from science and social science and to base clinical practice on such knowledge. Evidence-based medicine is portrayed as an alternative to medicine based on authority, tradition, and the physician’s personal experience. The role of politics is rarely mentioned. When discussed, politics is portrayed as what evidence-based medicine will avoid. Rational evaluation of evidence plays an important role in medicine. However, it is not an alternative to medical politics. Rather, evidence is a tool for institutional control and policy argument. Today evidencebased medicine is used to oversee individual physicians and the practice of medicine. It thus helps to alter the balance of power among doctors, payers, and patients. Changing medical practice requires the development of political, legal, and medical institutions that oversee medical care. Promoting medical practice based on evidence will therefore necessitate more, not less politics.