The complex, the exhausted and the personal: reflections on the relationship between evidence-based medicine and casuistry. Commentary on Tonelli (2006), Integrating evidence into clinical practice: an alternative to evidence-based approaches. Journal of Evaluation in Clinical Practice 12, 248-256.

It is a great honour to be asked to comment on Dr Tonelli’s paper ‘Integrating evidence into clinical practice, an alternative to evidence-based approaches’. Dr Tonelli has consistently been one of the more thoughtful commentators on the evidencebased medicine (EBM) debate and, in fact, published one of the first critiques of EBM from a philosophical point of view (Tonelli 1998). In this paper, I propose to explicate and critique some of the ideas found in Dr Tonelli’s paper. In addition, I hope to further the debate by questioning whether EBM and casuistry as outlined by Dr Tonelli are oriented more towards explaining or providing a basis for clinical decision making or towards the basis of a philosophy of medicine or the provision of care. I think this is an important distinction that has not yet been fully appreciated, and difficulties arise when one tries to treat them as identical pursuits.