Perspectives on evidence-based healthcare for women.

We live in an age of evidence-based healthcare, where the concept of evidence has been avidly and often uncritically embraced as a symbol of legitimacy, truth, and justice. By letting the evidence dictate healthcare decision making from the bedside to the policy level, the normative claims that inform decision making appear to be negotiated fairly—without subjectivity, prejudice, or bias. Thus, the term ‘‘evidence-based’’ is typically read in the health sciences as the empirically adequate standard of reasonable practice and a means for increasing certainty. Supporters believe that evidence-based medicine (EBM) can introduce rational order to the deliberative processes of healthcare decision making. It is perhaps puzzling, then, to come across critical perspectives (typically arising from the humanities and the more theory-driven social sciences) raising concerns about a seeming technogovernance being introduced by this deferral to the evidence where power interests can be obfuscated by way of technical resolve. The critics holding this minority view argue that technological solutions to problems of knowledge and practice cannot replace medicine’s normative content. Against EBM’s democratic leanings toward transparency and accountability, medical criteria alone cannot decide valueladen ethically charged decisions. This conflict of views is present in the field of women’s health. Supporters argue that an evidence-based approach to women’s health will improve health outcomes by critically analyzing the evidence base of women’s health research: identifying gaps and assessing the quality of the available evidence. Critics, however, worry that evidence-based practice will limit meaningful research into the sociopolitical determinants of women’s health by narrowing the range of admissible research methods and the types and sources of reliable evidence. Could an undervaluing of qualitative methods, for example, limit the important work of giving women voice and bringing their experience to bear on the healthcare encounter? I find the unfolding of the EBM debate in women’s health particularly interesting and worthy of focused attention because, unlike many other medical specialties that have largely suppressed dissent toward the evidence-based program, women’s health uniquely houses both insider and outsider perspectives with respect to the institutional knowledge and practices of biomedicine. This has to do with the evolution of the women’s health movement. The women’s health specialization originated as an outlier of biomedicine, growing out of a radical feminist grassroots movement that fostered a critical and questioning attitude toward the mainstream practices of biomedicine, which often failed to meet the specific needs of women or kept women uninformed about the issues that mattered to us. The movement was remarkably successful in bringing attention to the unique healthcare needs of women, resulting in the field being incorporated into that very mainstream both professionally and ideologically. It is, therefore, not surprising that some women’s health researchers will see the largely institutionally sanctioned evidence-based program as a vital tool for furthering the healthcare needs of women, whereas others will suspect implicit gender bias in its methodological assumptions. EBM is popularly defined as ‘‘the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.’’ It was initially framed as a ‘‘new paradigm’’ in medicine that ‘‘de-emphasize[d] intuition, unsystematic clinical experience, and pathophysiological rationale as sufficient grounds for clinical decisionmaking and stresse[d] the examination of evidence from clinical research.’’ Although the rhetoric of paradigms and revolutions has been toned down in more recent iterations, the promise still remains. EBM quickly rose to prominence in academic medicine throughout the 1990s because it promised to revolutionize medicine through the systematic evaluation of clinical research and the application of that research into bedside care. Even the critics of EBM will agree that as new discoveries continue to expand the breadth of medical interventions, treatments, and methods of care, the need for a more systematic approach to evidence development and application becomes increasingly critical. Without better information about the effectiveness of different treatment options, the resulting uncertainty can lead to the delivery of services that may be unnecessary, unproven, or even harmful. Improving the evidence base for medicine holds great potential to increase the quality and efficiency of medical care. There is a seeming obviousness to the evidence-based program. Some critics have asked, ‘‘What other kind of medicine can there be?’’ The epidemiological research suggests that the founding members of the evidence-based movement were correct in their claims that much of clinical medicine consisted of untested hunches, unsystematic clinical experience, and inferential pathophysiological rationale rather than empirical evidence. And so the move from the old ways of biomedicine to the new evidence-based approach is difficult to argue against.