The Tree of Wisdom: Maintaining epistemological health within an (emerging) evidence-free environment

Mounting concerns regarding the corruption of the clinical research enterprise by the pharmaceutical industry, as well as demonstrations of the inappropriateness of traditional research designs and consequent clinical guidelines to direct application to patient care, have led to challenges to the integrity of the evidence-based medicine (EBM) movement. However, the emerging crisis of confidence in clinical research should be seen as a threat to the viability of the entire healthcare system, not simply to EBM. Efforts of the EBM movement to represent itself as the brokers and mediators of the clinical research-healthcare interface are impediments to a full appreciation of the dilemma. Recognizing the implications of contrasting epistemological stances regarding the relationship of clinical research findings to healthcare policy and practice is essential to maximizing the value of research to the healthcare system. A synergy between empiricism-rationalism epistemologies, particularly conspicuous within the EBM movement, is identified as an important philosophical barrier to achievement of this goal. The notion of an evolutionary hierarchy of knowledge and wisdom is proposed as a vehicle to demonstrate a social constructivist alternative to a dualistic epistemology. Contrasting examples of social constructivist and empiricist-rationalist descriptions of integration of research with healthcare practice are provided for purposes of illustration