Ethics and evidence-based practice

Evidence-based practice is roughly the use of current best evidence in making decisions about the care of patients (Sackett et al. 1996). At first it seems hard to imagine how such practice could raise ethical concerns; and yet it has. These concerns are set out in the first section of this chapter. Much of the past discussion of these problems has focused on the epistemology of evidence, with critics suggesting that EBP is based on an overly narrow definition of evidence and knowledge. This chapter tacks differently, focusing instead on the epistemology of practice; in other words, what type of evidence or knowledge is needed in deciding how to act? Using the distinction drawn by Aristotle between practical and scientific knowledge it is suggested that evidence in the form of scientific knowledge, no matter how widely defined, cannot form the basis for practice because it cannot provide the goals that action requires; for EBP these must be provided from within practice itself, for example, nursing or surgery. However, ultimately the goals are provided by wider personal and social goals, in particular, human flourishing. Once this is accepted, it is possible to resolve the ethical concerns that have been raised about EBP, drawing on Aristotle's account of reasoning in the practice areas of craft knowledge and of practical wisdom.