Evidence-Based or Person-Centered? An Ontological Debate

puzzle-of-cancer_scientific-americanIn a recent paper published in European Journal for Person Centered Healthcare, I argue that the choice between EBM and person centered healthcare is a choice between conflicting ontologies, involving two very different notions of causation. While the methodology and practice of EBM seems perfectly supported by positivism and a Humean theory of causation, person centered healthcare does not. There is, however, a trend called the EBM Renaissance Movement, attempting to make EBM more person centered. In the CauseHealth project, we urge that person centered healthcare and practice requires a very different ontology and methodology from the positivist scientific ideal inspired by David Hume.

A genuine consideration of an individual’s health, I argue, cannot easily be accommodated within a methodology that ultimately reduces uniqueness and complexity to the sum of various averages, or derives individual propensities from statistical frequencies. If one assumes instead that complexity is simply a compositional matter and that individual propensities are generated statistically, EBM is clearly the way to go. A problem with this approach, is that there is an increase of so-called medically unexplained symptoms and other complex illnesses. Because of their bio-psychosocial complexity and individual variations, these conditions resist scientific scrutiny by methodologies that mainly generate statistical results and group averages.

CauseHealth promotes instead an alternative ontology of causal dispositionalism, emphasising holism over reductionism or dualism, genuine complexity over mereological composition, context-sensitivity and heterogeneity over robust regularities, causal singularism over universal laws and individual propensities over statistical frequencies. From this perspective, medical uniqueness and causal complexity should be expected for any illness. But this also means that epistemological priority should be given to qualitative approaches, clinical experience and to patient stories over quantitative methods. By moving away from the mono-causal model of illness, we can better understand medically unexplained symptoms, but also other complex and heterogenic illnesses.

These ideas are presented in more detail in ‘Evidence-Based or Person-Centered? An Ontological Debate‘, where I conclude:

Empowering the individual and giving back professional autonomy to the practitioner to consider the total situation of the subject before deciding on a treatment, seems preferable from a dispositional point of view. On this singular ontology, universally applicable truths in medicine are a misrepresentation of reality, which is multifactorial, heterogenic and highly contextual. To assume that the statistical generalisations carry more scientific force than the particular instances from which they are abstracted, would thus be a mistake. Causal singularism teaches us what PCH already knows: that each person is unique, and that one size does not fit all.

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