Evidence-based medicine and power shifts in health care systems.

It is important and urgent to question the relationship between evidence-based medicine and power shifts in health care systems. Although definitions of EBM are phrased as a scientific approach to medicine, EBM is a normative concept: it aims to improve medicine and health care. Both proponents and opponents use a normative concept. More particularly, they provide particular views on positions, responsibilities, possibilities, norms and relationships between professionals, patient groups, governments and other parties in health care and society. From this perspective, we want to analyse the role of EBM in modern western societies. By using citizenship theory, we will argue that the role of EBM is not fixed but depends on the relation between state and society. We will first analyse the fundamental change in western societies during the past decades, from modern to post-modern societies. Then, we will elaborate a fourfold model of possible relationships between state and society, and discuss the issue of how EBM may fit in, by giving some examples of the practice of EBM in different European countries. On this basis, we conclude to consider EBM as a public forum where proponents and opponents of EBM discuss diverse and possibly conflicting ways of changing medicine, health care, and health policy. This requires the incorporation of the perspective of citizens and their social networks, professionals with practical and tacit knowledge, and diverse public views on what is regarded as 'a good life'. Inasmuch as EBM is expected to be practically relevant, it ought to be tied to rather than separated from the normative world of emancipated patients and diverse health care practices. Proponents and opponents of EBM should be prepared to defend the normative claims and power effects that are inherently tied to any presentation of evidence.