Method as Argument: Boundary Work in Evidence‐Based Medicine

Abstract

In evidence‐based medicine (EBM), methodology has become the central means of determining the quality of the evidence base. The “gold standard” method, the randomised, controlled trial (RCT), imbues medical research with an ethos of disinterestedness; yet, as this essay argues, the RCT is itself a rhetorically interested construct essential to medical‐professional boundary work. Using the example of debates about methodology in EBM‐oriented research on complementary and alternative medicine (CAM), practices not easily tested by RCTs, I frame the problem of method as a fundamentally rhetorical problem, situated within a boundary drama, and deeply rooted in the discursive practices of science and medicine. The genre of the RCT report, for example, idealises the research process and can tilt the course of arguments about CAM, while the notion of efficacy can function as a rhetorically mobile boundary object that can redefine the very terms of debate. I suggest herein that arguments about method in CAM debates can productively be read, metonymically, as expressions of more general anxieties in medicine about knowledge and evidence, community values, and professional boundaries; as such, these debates can illuminate some of the rhetorical dimensions of EBM.

Keywords:

• Evidence‐Based Medicine
• Rhetoric of Science, Health, and Medicine
• Scientific Methodology
• Complementary and Alternative Medicine
• Clinical Trials

Acknowledgements

Portions of this essay were presented at the 2005 National Communication Association and the 2007 Society for Social Studies of Science conferences; I am grateful for the generative commentary at those sessions. I am also indebted to Judy Segal for her feedback over the course of this project.

Notes

[1] This is perhaps why Yves Gringas (2007), in a recent issue of this journal, expressed such reticence about associating his study of academic misunderstandings with rhetoric, choosing instead to situate his work with a related, but differently inflected, term: argumentation.

[2] In his well‐known theory of boundary‐work, Thomas Gieryn describes science in cartographic terms, where “[t]he epistemic authority of science is…, through repeated and endless edging and filling of its boundaries, sustained over lots of local situations and episodic moments, but ‘science’ never takes on exactly the same shape or contents from contest to contest” (1999, 14). This “edging and filling” of boundaries makes up much of the day‐to‐day life in labs, observatories, and the field. All of the data that scientists produce are interpreted, sorted, and sifted, results are tabulated and deemed significant or not, and conclusions are devised; all of these are, inter alia, rhetorical processes (see, e.g. Bazerman 1988, Myers 1990).

[3] Brecht’s well‐known “alienation effect” entails intentionally breaking the theatrical illusion so that viewers, unable to lose themselves within the fiction, remain critical of what they see.

[4] I ought to note at the outset that, while rhetoric, as a critical‐theoretical practice, is not about unmasking per se, this essay does a little unmasking to illuminate some of the disconnections between how medical researchers and practitioners (and policymakers, the media, and the public) think about the conduct and value of medical research, and how that research tends actually to unfold. I do not mean to set up a rhetoric‐reality binary through these theory‐practice disconnections, however; rather, I want to show that the RCT’s attendant value system is part of the professional fabric of medicine itself.

[5] Systematic reviews, though highest on the hierarchy, “can aggregate and evaluate but cannot change the basic information” furnished by RCTs (Feinstein and Horwitz 1997, 530).

[6] I should clarify that my claim here is not that biomedical theory sponsors a pedantically one‐size‐fits‐all approach to health care, or that CAM therapies are necessarily as individualised as their proponents suggest; these differences may be more apparent than real, although it is beyond the scope of this paper to speculate on the rhetoric of alternative medicine.

[7] Evelleen Richards’ (1991) study of the Vitamin C‐cancer controversy pre‐dates EBM’s rise but provides a detailed historical analysis of such factors at work in research and medical cultures.

[8] Miller defines genres as “typified rhetorical actions based in recurrent situations” (1995, 31).

[9] Swales (1990) usefully describes how experimental genres idealise models of research.

[10] In rhetorical terms, safety and efficacy function in debates about CAM as god‐terms, defined in Kenneth Burke’s lexicon as powerful, indeterminate terms that “[sum] up a manifold of particulars under a single head” (1970, 2). (Freedom and love are quintessential god‐terms.) As summary terms, they carry within them various, even conflicting, interpretations—they contain, Burke says, the resources of ambiguity, the fertile ground for persuasion.

[11] Star and Griesemer note that “[t]he creation and management of boundary objects is a key process in developing and maintaining coherence across intersecting social worlds” (1989, 393).

[12] Other pertinent examples of efficacy’s “mobility” could usefully be explored, such as outcomes measures, whose “hardness” can be scaled up or down to raise or lower the efficacy threshold.