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  • The Controversy of Evidence-based Psychiatry:Pragmatism as a Framework for Dialogue Rather Than Confrontation
  • Jorid Moen (bio)
Keywords

evidence-based medicine, framework, dialogue, particular purposes, usefulness

I am grateful to Peter Zachar and Mona Gupta for their relevant and constructive commentaries on my paper. I find it thought-provoking that whereas Zachar offers some ‘friendly amendments’ to my article, hoping to make it more appealing to scientific thinkers, Gupta, on the contrary, denies that pragmatism (nor any other approach) can ‘save’ evidence-based psychiatry. So Zachar’s point that some readers may find it difficult to categorize my position obviously makes sense. In the following, I hope to be able to clarify the role of the ‘vocabulary’ approach in the psychiatric debate concerning evidence-based medicine (EBM).

First, I should comment on Gupta’s objection to my claim that the pragmatist approach might enable EBM proponents and critics to “be brought to agree that the different perspectives they represent are both relevant and important for clinical practice” (Moen 2015, 53). I must confess that the expression ‘be brought to agree’ may have been unfortunate, insofar as it suggests that pragmatism will provide a (final) solution to the EBM controversies. Actually, pragmatism (as such) implies neither an endorsement nor a rejection of EBM. Rather this approach should be understood as providing a framework for the EBM debate. Whereas the usual way of framing the debate implies a search for the true basis for psychiatric practice—which has tended to make the debate stuck over diverging preconceived ontological and epistemological commitments— a pragmatist framing suggests a strategy for a possible dialogue to take place. Certainly, if the participants (pro- as well and anti-EBM) cannot be brought to acknowledge the point of alternative framings, the pragmatist approach would not be of much use for this purpose either, as I now explain. [End Page 71]

For a genuine dialogue to take place, a certain background of shared attitudes is required. In the context of the evidence-based psychiatry debate, a constitutive one would be that the general purpose of psychiatry is to offer the patients optimal treatment and care. But, as we know, already from here the opinions deviate. A way to circumvent entrenched confrontations is to promote a greater willingness to take opponents’ viewpoints seriously. Pragmatism may contribute to this by shifting attention from the true–false dichotomy toward the ends or goals that different forms of description may serve. To achieve this sort of understanding requires a willingness to hear the other party out, and to assess competing evaluations and modes of reasoning on their own premises. To epitomize this, let us take a closer look at Gupta’s claim that pragmatism cannot ‘save’ EBM in clinical practice. This is because, she argues, the theory of EBM actually implies that its vocabulary will trump others. Pointing at my wide-scope interpretation, she says that although this is more inclusive, is it “not actually consistent with the theory of EBM and the terms it lays out” (Gupta 2015, 64). In fact, this is exactly my point. The term ‘EBM’ turns out to be misleading when used in the wide-sense context, first and foremost as judged in terms of the EBM vocabulary itself.

When EBM is taken in the narrow-scope sense, however, its proponents have a case: It seems plausible to justify the purpose of EBM as a useful tool for evaluating the quality of certain kinds of scientific knowledge in terms like ‘systematic framing,’ ‘mathematical estimates of probability and risk,’ ‘assess the quality of evidence relevant to the benefits of treatments,’ ‘high degree of internal validity,’ and so on. The pragmatist approach does not in any sense downplay the value of scientific epistemologies and methods; scientific types of knowledge, and ways of ranging these, may indeed serve as useful tools for particular medical purposes. What the pragmatist view does reject, however, is the idea that these kinds of vocabularies have an absolute authoritative status, one that is not conditioned by a particular set of purposes, values, and ends.

Thus, when EBM proponents seek to justify the idea that the vocabulary of natural science should be the proper tool...

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