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Evidence based medicine: what it is and what it isn't

BMJ 1996; 312 doi: (Published 13 January 1996) Cite this as: BMJ 1996;312:71

Evidence-based Medicine: Why in Genuinely Protestant Countries?

Evidence-based Medicine: Why in Genuinely Protestant Countries?

In a fundamental contribution on how to practise and teach Evidence-
based Medicine (EbM) Sackett and his co-authors trace EbM back to mid-
nineteenth century France. Is that view valid? Is medical theory as
established by Bichat (1771-1802), Magendie (1783-1855), and Louis (1787-
1872) really the major root of EbM? Do the three represent a homogeneous
school of medical thinking? And why has France never since been a center
of EbM?

These questions call for an archeological search. The mere reference
to medical thinking in Paris cannot explain the rise of EbM in late
twentieth century in the face of a gap of more than 150 years.
Additionally, it has to be stated that Bichat and Magendie as the founders
of modern histology and experimental physiology respectively stand in
another epistemiological tradition than the founder of the “numerical
method”, Louis. Granted that the call for external evidence is a necessary
condition for EbM, this, however, cannot be held as a sufficient property
to differentiate it from conventional medicine. Relying on external
evidence provided by pathology and even epidemiology is also essential to
conventional medicine. Thus, it is not so much the quest for external
evidence, but rather the ways of both detecting respectively creating and
handling evidence that genuinely characterises EbM. So if we look at the
countries and the universities that cherished EbM right from the beginning
in the early 90s of the last century, it is mainly North America, the UK,
Scandinavia and the Netherlands. Thereupon it seems more than likely that
EbM, albeit also minted by empiricist thinking, can be figured as an
offspring of Protestant exegesis practised in the aforementioned

EbM could only thrive in Protestant countries as it obviously applies
principles of “scientific” exegesis to the growing body of medical
“tradition”. As Catholicism could base decisions on conflicting traditions
on a dogma-based principle of the “Pre” of the eminence, Protestant
theology lacking a single authority to settle theologic disputes had to
develop other solutions to come to terms with contradicting passages from
the scriptures and to clarify the relationship of the scriptures to other
sources of tradition such as the Fathers of the Church. Dogma or mere
negligence of whole parts of the Bible could not convince the believers
any more. Thus, scientific ways of reading the scriptures had to be
developed. Modern text criticism, literary criticism, for instance,
emerged, and methods evolved how to weigh different sources of tradition.
Researchers developed elaborate tools to dissect texts in order to come to
terms with contradictions. Yet, in order to avoid the danger of being
entangled in a mingle of loose ends of deconstructed texts, some kind of
hierarchy had to be reintroduced, some kind of principle that could guide
exegesis. The search for the canon in the canon began as a hermeneutical
exegetical challenge. Thus, even within the Scriptures texts were sorted
out into different levels of “importance” in a kind of similar way as
“tradition” of medical research is assorted to grades of evidence.

This, however, does not suffice as an explanation for the rise of EbM
in certain countries since Germany as one of the centers of Protestant
exegesis hasn’t intensively been promoting EbM. As a second condition sine
qua non serves a democratically shaped relationship among physicians since
the new methodology does not rely on the “Pre” of hierarchical eminence
and age per se, but dwells on the honest and transparent search for the
actual and best “substantiated” knowledge. This again is a Protestant
notion: Every lay person is entitled to read the Bible as any cleric is.

Thus, we are convinced that EbM is deeply indebted to or even
embedded in the grounds of historical critical exegesis arising from the
Protestant way of reading the Bible:
1. Everybody has got access to the „text“ without the preconditions of a
certain position.
2. Inconsistencies are neither smoothed out by dogma nor by negligence nor
by dictum of a final authority, but
3. review and appraisal follow criteria that are never absolutely set.
These criteria are constantly struggled for in a hermeneutical process
such as the refinement of EbM- grades.

In conclusion, the merits of EbM are not so much that it favors just
one form of methodology as the gold standard such as randomised control
trials, but its eminently new and challenging property is its kind of
“reformatory” way of reading the tradition according to principles that
everybody could intellectually follow. EbM both in its historical setting
of late twentieth century and in its self-conception as a method of
dealing with tradition is rooted in Protestant exegesis. Thus, it
represents a hermeneutical turn in medicine. Furthermore, both the
prerequisites and the consequences of EbM are in so far identical as a
democratically shaped interphysician relationship is supportive to EbM
and at the sime time evolves out of EbM.

Competing interests:
None declared

Competing interests: No competing interests

22 April 2004
Andreas U Gerber
research fellow
Markus Luengen, Karl W. Lauterbach
IGKE, U of Cologne, Gleueler Str. 176-178, 50935 Koeln, Germany