Hierarchy of Proof

Many of the issues described in Grossman and Mackenzie’s article deal with what I feel is a fundamental discord between our notions of what types of knowledge are most valid, particularly in a medical field. In this brief discussion, I borrow a number of notions put forward in D. Buchanan’s article “A New Ethic for Health Promotion: Reflections on a Philosophy of Health Education for the 21st Century” (2006, Health Education & Behavior, 33(3), 290-304). This article, while being a personal favourite for a number of reasons, is one I came across during a seminar on public health interventions and the motivations behind the creation and execution of them, in addition to, perhaps more importantly, the funding of these interventions. This is relevant to Grossman and Mackenzie’s discussion in that it allows us to envision a little more concretely how RCTs have shaped and, for the immediate future, will continue to shape public health policy and programming.

Buchanan discusses how medical models of scientific evidence underlie the majority of public policy as it relates to health, using a well-substantiated and convincing discussion that is worth visiting. This valuation of numbers over descriptors, “empirical” proof over “observational” proof, and so on, forms, in my mind, the very basis of the system that Grossman and Mackenzie seek to tackle in their article. I by no means am attempting to oversimplify this issue, but I think that it may be difficult to accept or perhaps even begin to imagine the issues with RCTs without considering that the reason we accept these types of results as so much better than observational and other methodological evidence typically grouped as that of the social sciences is based entirely on a medical model that has so permeated our consciousness of what evidence is really “true” evidence.

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