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  • Pragmatism and Evidence-Based Medicine:A Role for “Objectivity” and “Reality” in Our Vocabulary
  • Peter Zachar (bio)
Keywords

pragmatism, William James, Richard Rorty, evidence-based medicine

Having just spent 3 years completing a book that articulates a tough-minded Jamesian approach to the domain of psychiatry (Zachar, 2014), I am favorably disposed toward Jorid Moen’s analysis of the controversies surrounding evidence-based medicine (EBM). She does a good job of emphasizing the pragmatist inclination to get beyond fruitless philosophical disputes that can interfere with making progress on important issues. She offers a compelling argument for a pluralistic approach to psychiatry in which the relevance of evidence is evaluated by considering the purposes that the evidence may be used to serve. In her telling, progress is not narrowly understood as a successful mirroring of a fixed objective reality; rather, it is akin to a generative evolutionary process. Hopefully, problems are solved and put to rest, but progress also includes a reformulation and expansion of our perspective in which new problems are recognized and additional standards for success are developed.

For instance, instead of construing progress narrowly as an expectation that in 150 years we will have a cure for depression like we have a cure for syphilis, progress can be construed widely wherein we expect in 150 years hence to have many new options for making interventions. A plurality of goals would be articulable for problems that future historians of psychiatry would see as descendants of the current concept of depression. In Richard Rorty’s (1979) terms, future generations of psychiatrists will have more things to say about depression than we do now, just like biologists have more things to say about the body than Aristotle did.

When discussing philosophical contrasts like subjective versus objective and relativism versus realism, pragmatists consider what use each concept in the contrast may have—and they acknowledge [End Page 67] that each contrast may do some good work depending on the context. As such, pragmatists can be hard to categorize philosophically as either realists or relativists and are easily misunderstood.

Perhaps for similar reasons, some readers may be less clear about how to categorize Moen’s position in that she is both critical and supportive of EBM. She seems to agree with those critics who emphasize the limits of EBM by pointing out its inconsistencies and who assert that EBM is interfering with a comprehensive approach to psychiatric practice (Gupta 2009; Thomas, Bracken, and Timini 2012). Her claim that the goals of professional psychiatry are to cure sometimes, to relieve often, and to comfort always is consistent with this critical spirit. Moen’s agreement with the advocates for EBM seems to lie in her wanting to retain a role for a systematic EBM framework in psychiatry. She does, however, seek to broaden the scope of EBM by considering all the evidence that may be relevant in helping address the variety of goals that psychiatrists (and their patients) may articulate.

Moen’s pragmatism does not escape many of pragmatism’s perceived shortcomings. For example, Moen notes that the ideal goal of EBM—to integrate the best research evidence with clinical expertise and the patient’s unique values and circumstances—is so general and commonsensical that hardly anyone would disagree. The same can be said about pragmatism. Who would disagree with an open-minded attempt to see what it is that opposing perspectives each have to contribute to psychiatry? Pragmatism in this sense, as Moen admits, can be disappointingly bland.

Borrowing a phrase from Jennifer Hansen (2013), in this commentary I offer some friendly amendments to Moen’s article with the hope of making it more appealing to scientific thinkers. My purpose is to expand upon her pragmatism by arguing that concepts like objective and reality, as conceptual tools, have useful roles to play for pragmatists.

Pragmatists have different ways of talking about what it is that they are doing—with a currently popular way being that of Richard Rorty (1991). Rorty was a classicist by training and an analytic philosopher in the early years of his career. After gaining philosophical celebrity, he became more immersed in postmodernism and continental philosophy. His immersion in...

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