Beware those offering "gold standards": evidence-based medicine and the potential for institutional change in clinical-medical provision.

According to its advocates, Evidence-Based Medicine (EBM) represents an attempt to democratize health care (EBM Working Group 1992; Sackett et al. 1996, see also Oliver and McDaid 2002) by providing both patients and clinicians with better quality, objective information about the performance of medical procedures, pharmaceuticals and treatments. It aims to furnish a systematic review of medicine: a "gold standard" in "best practice."

EBM has to date, had a spectacular history. Prior to 1992, the term was absent from the medical literature; yet in fifteen years the terminology and its emphasis has become embedded within Occidental medical education and research--it has taken the medical community by storm (Kristiansen and Mooney 2004). Its emergence and subsequent rapid adoption surpasses that even of the notion of social capital in the social sciences. Seldom in the history of science and scientific practice can an emergent approach have been adopted so readily; indeed, converts occasionally adopt an evangelical zeal.

Despite EBM's laudable objectives there are sound reasons why caution should be exercised regarding its methods, adoption, subsequent proliferation, and potential to invoke institutional change. Extensive criticisms from medical, methodological, ethical and even (mainstream) economic perspectives are emerging. Yet institutional economics has largely been absent from this discussion and analysis. The aims of this paper are two-fold: to highlight the lacuna in the institutionalist literature, and second, to note the potential for insidious institutional change.

At the outset of the arguments presented here two qualifying notes are made: First, the term "instrumentalism" is not employed in the manner defined by John Dewey; instead I adopt its more positivistic and utilitarian rendering in referring to actions and theories as possessing no intrinsic value--their value lying in their consequences. Second, clinical-medical care is the preferred narrative, since care of this nature is usually provided in a particular institution centering on the social relationship between clinician and patient. By contrast, health care broadly conceived involves a richer milieu of institutions not necessarily focusing on the clinician-patient relation or the clinical-medical encounter.

To my knowledge, Keaney and Lorimer (1999) offer the only institutionalist analysis of the impact of formalized clinical governance (something that EBM is closely associated with, certainly in the UK). Their valuable contribution analyzed the clinical-medical system in Scotland. This paper endeavors to present a more abstract and theoretical consideration of the potential nature of institutional change associated with EBM. It is explicitly recognized that EBM is not the only initiative or source of institutional change in clinical-medical care (for an example of other initiatives encouraging instrumentalism, see McMaster 2004), and that the adoption of EBM principles varies considerably, both within and between clinical-medical care systems. Moreover, the paper by no means is intended to provide a comprehensive analysis of the rise of EBM and its impact on clinical-medical care institutions and systems. Much speculation could be, and doubtless has been, exercised attempting to rationalize EBM's incredible trajectory. Plausible explanations include: EBM representing an innovative progression, due in large part to advances in computing technology, of established clinical practice; a consequence of the rise in consumerism and decline in trust in the clinical professions; an attempt to reduce medical errors in an increasingly litigious society; an aspect of wider fiscal pressures and attempts to contain costs, and a manifestation of wider social trends that promote scientism, or seeming objectivity, and greater quantification (see, for example, Aasland 2001; Birch and Gafni 2004; Kristiansen and Mooney 2004; Miles et al. 2004, and more wide-ranging commentaries on scientism and the culture of quantification, such as Dupre 2005; Porter 2004; and Shenhav 1999). Instead, the paper attempts to make some reasoned conjectures to highlight the emergence of an agenda requiring attention.

These caveats in mind, it is contested that EBM privileges a particular type of evidence--randomized control trials (RCTs) and meta-analysis--that acts to relegate other forms of medical evidence. EBM has the potential to structure change by changing the dialogical context of the clinical-medical encounter into a reductionist rule-based practice grounded in the bio-medical paradigm, which relegates the significance of social, historical and even individual contingencies of health. This carries the capacity to objectify the individual patient, thereby erasing the individual from consideration, as the general is applied to the particular. EBM, then, potentially erodes deontological considerations and contexts of practice. The focus is on outcomes with procedure adopting an instrumental character. Concisely, the social construction of knowledge and illness are at best attenuated in a narrative reflecting an overarching mechanistic frame. This is far from inevitable, as professional medical practice draws upon a plethora of repertoires predicated on culture, social context and space; yet the trajectory remains.

The following section briefly outlines the properties of EBM. The third section reviews the nature of the medical and standard health economic critiques, while the following draws on the approaches of Dewey, Charles Sanders Peirce, and Douglas Walton in particular as bases for questioning the claims of EBM advocates and for conceptualizing the nature of institutional change that may be prompted by EBM. The penultimate section sets out a range of theoretical conjectures on the institutional impact of the unfettered adoption of EBM.