Anomalies Persist, So Does the Problem of Harm

We are very grateful to Mona Gupta and Peter Zachar for their commentaries on our paper. In our view, the main challenge for both commentators is this: do they have empirical evidence to refute our rejection (on evidence-based grounds) of the primacy of the current technological paradigm in psychiatry? Although opinions may differ about our choice of the philosophical tools we use to interpret the facts, unless there is good evidence to contradict our basic premise, their arguments will fail to reach the evidence-based medicine (EBM) gold standard that they support. We do not believe their commentaries present any empirical evidence that contradicts our critique. Before we respond, we wish to stress two points.

First, we are not opposed to EBM. We believe that EBM represents a significant advance in the application of scientific principles to assist in developing a clear and rational basis for establishing the safety and efficacy of treatments used in medicine. Our position is that EBM, when properly applied to treatments in psychiatry, produces data incompatible with the technological paradigm. Furthermore, these data may be interpreted using Kuhn’s work as anomalies. We therefore highlight the importance of distinguishing between the use and application of EBM in medicine, and its use and application in psychiatry. We are interested to gauge whether or not the commentaries engage with the evidence of anomalies.

Second, we wish to comment on the possible harms that can arise from a continued adherence to the technical paradigm in psychiatry. If we fail to pay due attention and engage seriously with these anomalies, perhaps in a desire to ‘cling’ to the dominant paradigm, we run into the danger of minimizing the risk of harm that may result from our ‘technologies.’ The history of psychiatry is a catalogue of well-intentioned but tragically harmful interventions, from dental extractions, thyroidectomies, hysterectomies, and leucotomies, to insulin coma therapy and electroconvulsive therapy (ECT). EBM is concerned not only with efficacy, but also with the risk of harm that may arise from treatment. Properly protecting patients means engaging critically with data from EBM, and confronting what it says about all aspects of our practice. If our interpretive framework (the technical one) is inadequate, we must develop a better one rather than try to force the data into an incompatible theoretical construct, which renders ‘believers’ vulnerable to blind spots including possible harms that result from the favored technical and biomedical practices developed within that dominant paradigm.

We broadly agree with Mona Gupta’s commentary, and are grateful to her for her helpful distinction between EBM on the one hand, and biomedical psychiatry on the other. As we made clear in our paper, we use the adjective ‘technological’ rather than ‘biological’ or ‘biomedical’ because EBM has been applied to interventions that are both biomedical and psychological. Our problem is primarily with the technological paradigm, but in our view this distinction, although helpful, is by no means as clear as Mona Gupta seems to think. There is a serious problem with the way in which EBM has been misused by those who disregard the flimsy evidence for the differential efficacy (e.g., by diagnosis) of psychiatric treatments that EBM yields. EBM is extremely successful in somatic medicine, where the randomized, controlled trial and hierarchies of evidence play a vital role in helping clinicians and patients to decide what treatments are safe and effective, despite the distorting influence of the pharmaceutical industry. EBM is valued in psychiatry because its use creates the impression that psychiatry is a scientific discipline with a rational causal and diagnostically based, empirically established treatment protocols just like other areas of medicine, when the reality is, as we have pointed out, quite different.

The technological paradigm that forms the current basis for psychiatric theory and practice relies on categorical diagnostic systems that have poor validity. The philosopher Carl Hempel (1961) argued that the validity of a concept like schizophrenia depends on the extent to which it represents a naturally occurring category. If it does, then there...