Epistemologies of evidence-based medicine: a plea for corpus-based conceptual research in the medical humanities

Abstract

Evidence-based medicine has been the subject of much controversy within and outside the field of medicine, with its detractors characterizing it as reductionist and authoritarian, and its proponents rejecting such characterization as a caricature of the actual practice. At the heart of this controversy is a complex linguistic and social process that cannot be illuminated by appealing to the semantics of the modifier evidence-based . The complexity lies in the nature of evidence as a basic concept that circulates in both expert and non-expert spheres of communication, supports different interpretations in different contexts, and is inherently open to contestation. We outline a new methodology that combines a social epistemological perspective with advanced methods of corpus linguistics and elements of conceptual history to investigate this and other basic concepts that underpin the practice and ethos of modern medicine. The potential of this methodology to offer new insights into controversies such as those surrounding EBM is demonstrated through a case study of the various meanings supported by evidence and based , as attested in a large electronic corpus of online material written by non-experts as well as a variety of experts in different fields, including medicine.

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Medicine, Health Care and Philosophy (2021) 24:621–632
https://doi.org/10.1007/s11019-021-10027-2
SCIENTIFIC CONTRIBUTION
Epistemologies ofevidence‑based medicine: aplea forcorpus‑based
conceptual research inthemedical humanities
JanButs1· MonaBaker2· SaturninoLuz3· EivindEngebretsen4
Accepted: 26 May 2021 / Published online: 31 May 2021
© The Author(s) 2021
Abstract
Evidence-based medicine has been the subject of much controversy within and outside the field of medicine, with its detrac-
tors characterizing it as reductionist and authoritarian, and its proponents rejecting such characterization as a caricature of
the actual practice. At the heart of this controversy is a complex linguistic and social process that cannot be illuminated by
appealing to the semantics of the modifier evidence-based. The complexity lies in the nature of evidence as a basic con-
cept that circulates in both expert and non-expert spheres of communication, supports different interpretations in different
contexts, and is inherently open to contestation. We outline a new methodology that combines a social epistemological per-
spective with advanced methods of corpus linguistics and elements of conceptual history to investigate this and other basic
concepts that underpin the practice and ethos of modern medicine. The potential of this methodology to offer new insights
into controversies such as those surrounding EBM is demonstrated through a case study of the various meanings supported
by evidence and based, as attested in a large electronic corpus of online material written by non-experts as well as a variety
of experts in different fields, including medicine.
Keywords Evidence-based medicine· Corpora· Basic concept· Social epistemology· Evidence
Introduction
Ever since the rise of modern medical science in the early
nineteenth century, medical practice has been closely associ-
ated with science and research, and evidence has grown to
become a key term in modern medical discourse. This has
been particularly true since the emergence of the evidence-
based medicine (EBM) movement in the early 1990s. The
basic idea in EBM is that clinical and health policy decisions
should not be based merely on intuition, expert opinion, or
pathophysiological reasoning. Such sources are considered
potentially biased and unreliable. Evidence-based decisions
should integrate expertise and patient preferences with the
“best available external evidence from systematic research”
(Sackett etal. 1996, 71: 78). Evidence, in the EBM sense of
the word, is mainly associated with randomized controlled
trials (RCTs), i.e. comparative experimental intervention
studies, which are considered the ‘gold standard’ for assess-
ing cause-effect relationships between an intervention and
its outcome; the findings generated by RCTs are likely to be
closer to the true effect than the findings generated by other
research methods (Evans 2003). Ideally, such trials should be
summarized through systematic reviews and form the basis
for clinical guidelines for clinicians and decision makers
following standardized procedures. Other research designs
such as observational studies and even qualitative studies are
officially included in the EMB framework, but in practice are
treated as less reliable sources of evidence. Indeed, EBM has
developed a framework for ranking evidence in a hierarchy
that features simple observational methods at the bottom and
moves on to increasingly rigorous methodologies, notably
RCTs and systematic reviews, at the top.
This received ranking of evidence and the singular,
restricted conceptualization of evidence it perpetuates are
not always helpful, as the current crisis has amply illustrated.
For instance, Greenhalgh (2020) has recently demonstrated
* Eivind Engebretsen
eivind.engebretsen@medisin.uio.no
1 Boğaziçi University, Istanbul, Turkey
2 University ofOslo, Oslo, Norway
3 Usher Institute, Edinburgh Medical School, University
ofEdinburgh, Edinburgh, Scotland,UK
4 Faculty ofMedicine, University ofOslo, Blindern, BOX
1078, 0316Oslo, Norway
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622 J.Buts et al.
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that EBM fails to acknowledge the whole fabric of evidence
relevant to the question of using facemasks as a measure
against the spread of COVID-19. Although there are few
relevant RCTs to warrant decisions on this issue, several
other pertinent strands of evidence are available. Along
with epidemiological studies, Greenhalgh (2020) refers to
the physics of droplets and aerosols, the material science of
masks, mathematical modelling, political and behavioural
science, economics, and anthropology in order to answer
various questions regarding the use of facemasks. In addi-
tion, she draws on semi-scientific sources such as hand-
books, newspaper articles and patient experiences. These
can all be considered sources of different types of evidence,
she claims—although they address different purposes. An
anthropological study about cultural attitudes or compliance
does not measure the ‘true effects’ or statistical magnitude
of an intervention, but that does not make its findings unreli-
able as evidence in every sense of the word. They provide
evidence of a different kind.
The same argument may be extended to what constitutes
evidence for non-academic groups, including groups that
question and challenge conventional medicine. Anti-vaccine
groups and various proponents of alternative medicine have
contested the meanings and uses of evidence and associated
concepts in EBM, partly in response to what they perceive
as the hierarchical, authoritarian and impersonal character of
the medical community (Browne 2018). These groups sup-
port their views through various practices of evidence, and
many of them draw on knowledge sources associated with
traditional academic institutions. EBM cannot understand
the motivations of those promoting anti-vaccination theo-
ries if it simply dismisses their arguments as non-evidence.
Without suggesting that the alternative basis of evidence
these groups promote must be accepted, there is a need to
identify and analyse the discursive means by which they
support their claim to scientific legitimacy (Kata 2012).
By understanding what concept of evidence informs their
behaviour, the arguments put forward by these groups can be
better addressed and questioned, and, where necessary, mis-
information can be targeted by effective counter-information.
This article is a plea for initiating a new research strand
within the medical humanities that combines advanced
methods in corpus linguistics and critical discourse analy-
sis with some of the assumptions of social epistemology
and conceptual history in order to address two main aims.
The first is to investigate the genealogy and contestation of
a constellation of concepts that has underpinned the practice
and ethos of modern medicine since the early nineteenth
century. This requires access to a large body of electronic
corpora of texts originating at different historical moments
and drawn from a diverse range of genres, including medical
journal articles, WHO and CDC reports, systematic reviews,
guidelines and internet blogs. To demonstrate the potential
of the proposed methodology in the absence of access to
these resources, which we are planning to build and share
with the research community in the near future, we will here
present a case study exploring the variety and complexity of
meanings currently associated with the concept of evidence-
based in modern medicine, as well as the various forms of
contestation it has invited within and beyond the medical
community. We attempt to unpack this complex concept by
analysing the patterning of its individual components (evi-
dence and based), as attested in the Genealogies of Knowl-
edge corpus of Internet English (see “Data, methods and
theoretical underpinnings” section).
The second aim of our research group is to develop
models for situated epistemologies and ontologies able to
cope with the huge challenges to established frameworks of
knowledge in modern medicine that the COVID-19 crisis
has particularly thrown into relief in recent months. This is
a more ambitious aim which we hope to pursue through a
series of future case studies. For our immediate purposes,
we focus mostly on demonstrating our proposed methodol-
ogy and contributing to the (limited) literature on the mean-
ings of evidence-based as a key concept in modern medicine
and a growing range of other areas of practice (“Analysis”
section).
Data, methods andtheoretical
underpinnings
This article supports its plea for a new research strand in
the medical humanities with a small case study of the lin-
guistic patterning of evidence-based in a corpus of Internet
English, and what this patterning reveals about the potential
for this widely used term to generate different meanings in
different contexts, in part because of the numerous meanings
supported by each of its constituent elements (evidence and
based). The analysis is rooted in the theoretical assump-
tions and draws primarily on the methodological innova-
tions of two areas of scholarship: corpus linguistics (CL)
and critical discourse analysis (CDA). Both insist on the
primacy of attested uses of language, focus on identifying
repeated patterns, and offer generalizations based on close
analysis of such patterns. Corpus linguistics offers theoreti-
cal notions that assist in the analysis of the semantic and
affective dimensions of key concepts such as evidence and
evidence-based, as revealed in actual use across many texts,
authors and historical periods, depending on the design of
the corpora to which the analyst has access. These include,
for example, the notion of collocation (the habitual co-
occurrence of words), semantic preference (the tendency of
a certain word to collocate with other words from a specific
semantic set), and semantic prosody (collocational patterns
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that express the speaker or writer’s attitude or evaluation)
(Sinclair 1991; Louw 2000).
Influenced by the work of Michel Foucault, CDA seeks to
explain the conditions of possibility for the recurrent use of
particular linguistic patterns by examining the social prac-
tices and ideological context in which they are embedded.
CDA assumes that any discursive event is shaped by the
institutions and social structures in which it is embedded but
also shapes them; in other words, that “discourse is socially
constitutive as well as socially conditioned” (Wodak and
Fairclough 1997, p. 258). Corpus-based CDA integrates
the two theoretical traditions to arrive at more holistic and
detailed descriptions of a large body of data rather than lim-
ited samples of language in use, while maintaining the focus
on discourse as constitutive of social relations. By combin-
ing large scale quantitative and qualitative analyses of lan-
guage in use, Corpus-based CDA avoids the overemphasis
on statistical methods typical of many corpus linguistic stud-
ies, including the very few that have recently been conducted
in the field of medicine (Aiello and Simeone 2019). The
emphasis on discourse as ‘structured forms of knowledge’
rather than text as a linguistic artefact means that Corpus-
based CDA studies typically supplement statistical analy-
ses with close examination of extended stretches of text, a
methodology that is more consistent with the tenets of social
epistemology and the objectives of the strand of research we
advocate here.1
Work in Corpus-based CDA generally focuses on the
ideological implications of linguistic patterns associated
with lexical items such as migrants or climate change in the
media (Baker etal. 2008), or metaphorical uses of language
in specific sites of communication (Wei 2016). In the field
of healthcare and education, Semino etal. (2015) explore
the use of metaphors of Violence and Journey among cancer
patients and health professionals on online forums, and Cle-
land and Palma (2018) examine the discourse of UK deans
of medical schools, arguing that it leads to the othering of
widening participation applicants and exacerbates social
divides. Our proposed methodology goes beyond this type
of analysis in one important respect.2 It focuses not on lexi-
cal items or metaphors but on basic concepts, as defined and
understood in the field of conceptual history. Basic concepts
have considerable currency in both specialist and public dis-
course. They “combine manifold experiences and expecta-
tions in such a way that they become indispensable to any
formulation of the most urgent issues of a given time”, and
“are always both controversial and contested” (Koselleck
1996, p. 64). Precisely because of these characteristics, they
are “pivots around which all arguments turn”, and their his-
tory cannot be separated from the history of discourse, in
Foucault’s sense of the term (ibid.:65). Given the entan-
glement of their scientific and public meanings and uses,
a study of a basic concept such as evidence in medicine,
for example, cannot be separated from its study in every-
day, non-specialist use, nor can it be restricted to a specific
genre or register. Our focus on basic concepts and constel-
lations of concepts rather than lexical items or metaphors
requires compiling thematic corpora that cut across many
genres rather than, for instance, corpora solely constituted
of newspaper articles or case reports.
Finally, the research approach suggested in this paper is
theoretically situated within the broad and rather ambiguous
tradition of social epistemology. This branch of epistemol-
ogy was systematically developed by Steve Fuller in the late
1980s but was first conceptualized by the library scientist
Jesse Shera, who defined it as “the study of knowledge in
society” and suggested that its focus “should be upon the
production, flow, integration, and consumption of all forms
of communicated thought throughout the entire social fab-
ric” (Shera 1970, p. 86). Social epistemology later took two
divergent directions. According to one of its pioneers, Alan
Goldman, social epistemology should maintain the truth-
oriented ambition of traditional epistemology, but with an
emphasis on collective agents, rather than individual agents:
“social epistemology is, in the first instance, an enterprise
concerned with how people can best pursue the truth […]
with the help of, or in the face of, others” (Goldman and
O’Connor 2019, p. 1). Fuller favours a different program
that is more inspired by science and technology studies and
a social constructionist perspective on knowledge, and based
on “the assumption that a key feature of a claim’s episte-
mological status is its need to be certified by an appropri-
ate social group before passing as knowledge”, as stated in
the announcement of his new journal Social Epistemology
in 1987. In this latter version, and as originally defined by
Shera, social epistemology underpins the following four
dimensions of our approach to the study of evidence, which
are consistent with our focus on basic concepts as outlined
above:
1. When exploring the concept of evidence, we are not only
concerned with science but with the whole social body
of knowledge.
1 In CDA and beyond, criticism of corpus-based research generally
focuses on the disproportionate attention paid to single words and
phrases rather than larger textual units, and on the difficulty of con-
vincingly relating textual patterns to extra-textual realities. In addition
to linguistic and cultural decontextualization, the proper use of quan-
tification and visualisation techniques is heavily debated. Taylor and
Marchi (2018) offer a constructive overview of abiding methodologi-
cal issues.
2 It also goes beyond some of the corpus-based studies in the phi-
losophy of science that focus on differences in writing styles between
historical and experimental sciences (Argamon etal. 2005; Argamon
and Dodick 2006).
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624 J.Buts et al.
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2. We consider knowledge not merely as an individual but
primarily as a social endeavour involving the whole
social fabric.
3. We consider the epistemological questions of what can
be known and how knowledge claims can be assessed
as relative to the social processes in which the knowl-
edge is produced. This is not the same as arguing that all
knowledge is equally true; our argument, rather, is that
truth is only one of the situated principles according to
which knowledge claims are or can be assessed.
4. We approach the study of evidence from an empirical
point of view by analysing and assessing how the con-
cept is actually used in various discourses. As such, our
approach relates to recent developments in the field of
experimental medical philosophy, which share the over-
all ambition of promoting empirical methods within phi-
losophy and the assumption that conceptual analysis can
be informed by empirical data (Veit 2020). However,
while our approach is empirical it is not bound to any
experimental method, and where experimental philoso-
phy has mostly used surveys, our study rather draws on
corpus linguistics and conceptual history.
Combining this social epistemological perspective with
corpus linguistics and elements of conceptual history, we
argue that the concept of evidence should not be studied
solely in the restricted environments that lay claim to a
specific notion of it. Evidence can only be understood and
assessed within the diverse discursive environments in
which the concept actually operates.
The data on which the analysis offered in “Analysis” sec-
tion is based consists of the full Genealogies of Knowledge
(GoK) corpus of Internet English. GoK is a multidiscipli-
nary research project that has built corpora of ancient Greek,
Latin, medieval Arabic and modern English. Each of these
languages has served, at a particular point in time, as a lin-
gua franca governing the intercultural circulation of knowl-
edge. In the GoK browser environment, these corpora are
queried separately, but their content is connected via trans-
lation and other forms of mediation, and thematically the
corpora are all constructed around broad notions of scientific
and political discourse. In other words, all texts contained
in the corpora have contributed to our contemporary con-
ceptual apparatus for expressing notions such as expertise,
proof, and evidence, but also justice, rights, or democracy.
For the English language, the corpus is divided into two
main subcorpora. One corpus represents canonical academic
knowledge, usually published in book form, whereas the
other corpus represents a wide variety of publications gath-
ered from the Internet, more specifically from media seeking
to give voice to multiple opinions that contest the political
and scientific consensus arguably found in traditional print
and broadcast media. The texts in the GoK Internet corpus
consist mostly of short articles and blog posts written from
a polemic or activist perspective, published within the last
15years. This corpus (totalling 5.6 million tokens) provides
all data discussed below and includes a total of 3476 texts
from over 35 outlets, including ScienceBlogs, Discover Soci-
ety, openDemocracy, and UCSUSA (Union of Concerned
Scientists).3 All texts are written in the English language,
and the corpus is not meant to provide a representative over-
view of ‘the Internet’—something that would be impossible
to attain. Rather, it provides a broad sample of Anglophone
voices represented in online alternative media. The corpora
compiled in the context of the GoK project are queried via
a freely accessible concordance browser.4 The main inter-
face is a classic keyword-in-context (KWIC) display, which
returns concordance lines in response to a search for a given
keyword; longer stretches of text are viewed by means of an
‘extract’ function, designed in compliance with copyright
regulations (Fig.1). In addition to the concordance interface,
the software also offers a range of visualization tools (Luz
and Sheehan 2020), some of which feature in the analysis
we present here.
Analysis
In assessing the controversy around the adequacy of EBM,
Martini (2020) asserts that disagreement partly results from
“ambiguity about the concept of evidence”, which often
goes largely “unanalysed” and therefore “contains the con-
tradictions that allow both camps to defend their positions
and charge their adversaries”. Similar concerns about the
lack of critical reflection on the meanings of evidence and
evidence-based have been raised in relation to other areas
of evidence-based practice, where analogous controversies
have arisen. For instance, Kvernbekk (2011, p. 515) notes
that evidence-based has become “a buzzword in contempo-
rary educational debates (and also in medicine and policy-
making, among other areas)”, and resorts to philosophy to
unpack the meanings of the two components of the term,
namely evidence and based. Rather than pursue this dis-
cussion in the realm of philosophical debate, our proposed
methodology involves analysing attested uses of the two
concepts that feed into different interpretations of evidence-
based medicine—evidence and based—in a large electronic
corpus of texts written by non-specialists using evidence,
-based, and evidence-based in arguments about everyday
3 The full contents the corpus can be consulted at http:// genea logie
sofkn owled ge. net/ corpo ra/ inter net- corpus/. Corpus building is still
ongoing, but upon request the authors can provide a list of all articles
included at the time of writing.
4 http:// genea logie sofkn owled ge. net/ softw are/.
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Epistemologies ofevidence‑based medicine: aplea forcorpus‑based conceptual research in…
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topics such as climate change and human rights, as well
as specialists on various areas of Evidence-based Practice,
including EBM. Understanding the variety of meanings that
basic concepts such as evidence assume in general discourse
and in different contexts may afford us some insight into
how they came to be condensed and streamlined to support
a specific conception of medical practice associated with
the EBM model and dominant among some, though by no
means all members of the medical community.
Evidence intheGoK Internet corpus
In the GoK Internet corpus, there are 4402 occurrences of
the keyword evidence, placing this basic concept in a very
high (118th) position in the general frequency list. Evidence
occurs with higher frequency in the corpus than lexical items
that are very common throughout the English language, such
as same and since, and is also more frequent than many
other terms that encode basic concepts characteristic of our
thematically designed corpus, such as policy and society. At
N−1, the position one word to the left of the keyword, the
most frequent collocates are the (719), of (359) and no (229).
The and of are the two most frequent words in the overall
corpus, so their high frequency in relation to evidence is not
immediately informative. In contrast, no generally occurs
much less frequently, and thus the pair no evidence makes
for an interesting collocation, as can be seen in Fig.2.
Fig. 1 Example screenshot of a KWIC concordance of evidence from the GoK interface, ordered by the lexical item in position 1 to the left of
the keyword
Fig. 2 Mosaic of evidence
collocates in the GoK Internet
Corpus (cropped). The size of
the tiles is relative to the words’
collocation strength, calculated
using the MI3 measure (a vari-
ant of Mutual Information less
biased towards rare words),
omitting log transformation.
Local view is selected within
the interface, meaning that
significance is represented
within each position to the left
or right of the keyword, rather
than across all positions (global
view). See Luz and Sheehan
(2020, pp. 11–12) for a broader
discussion of the visualization
tool
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626 J.Buts et al.
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Many instances of the collocation no evidence form part
of the larger pattern no evidence of (64), a phrase that in
turn occurs in several longer sequences, as in the following
examples:
There is no evidence of a link between autisms and
vaccines. (Hoofnagleand Hoofnagle 2008; Denialism
Blog)
There is no evidence of a link between glyphosate in
the food chain and autism, diabetes and obesity. (Zaruk
2016; The Risk Monger)
Both examples are taken from individual blogs concerned
with a broad range of scientific matters, yet remarkably, the
same exact phrasing occurs twice 8years apart, and both
times in an argument against purported connections between
chemicals and health disorders. The first example speaks of
a supposed link between autism and vaccination, and while
no relevant causality has been established in the medical
literature, belief in this relation seems to have only grown
over the past decade and developed among large parts of
the global population into a general aversion to vaccination.
Indeed, while there are currently several vaccines avail-
able for COVID-19, this does not necessarily mean that the
problem of ‘vaccine hesitancy’ is easily overcome (Harrison
and Wu 2020). A central problem in this regard is that it
may be feasible in the short term to provide evidence for the
efficacy of a vaccine, but it is much harder to establish its
safety. Indeed, variants of the common expression ‘absence
of evidence is not evidence of absence’ occur several times
in the corpus. The expression illustrates a logic on which
the sceptic can always fall back when defending a suspi-
cious position in relation to the long-term health effects of
vaccines, or to any other hypothetical consequence of multi-
faceted bodily or social interventions.
The second example intervenes in the glyphosate con-
troversy, the debate about whether the use of this herbicide
is harmful to humans. Glyphosate is domestically known
for being the main active ingredient in Roundup, but is also
used on a vast scale in agriculture. Studies on its effects are
so far inconclusive. Chemical interactions produce complex
effects, and while studies declaring the herbicide safe are
often considered questionable for being produced by com-
mercial stakeholders, several studies condemning the use
of glyphosate are criticized for being “unsupported by evi-
dence” (Mesnage and Antoniou 2017, p. 4). In this respect,
providing evidence would mean incontestably showing that
glyphosate in the environment causes disease. However, pro-
ponents of a stricter regulation of pesticide and herbicide use
regularly invoke the “precautionary principle”: when in a
state of “scientific uncertainty”, do not take risks (Kudsk and
Mathiassen 2020, p. 216). The argument cannot easily be
resolved, as both sides come to rely on the rhetorical fallacy
termed argumentum ad ignorantiam (Walton 1999). Those
critical of glyphosate argue that, since there is no proof of
safety, the chemical is unsafe, whereas their opponents, in
the absence of proven harmful effects, declare the herbicide
safe. Thus, the burden of proof is passed back and forth,
and a consensus cannot be reached. Consequently, further
oppositional entrenchment can be expected, and notably,
both articles from which the above examples are derived
ultimately resort to name-calling: Hoofnagleand Hoofnagle
(2008) frame the discourse of theiropponents as “denialist
claptrap”, and Zaruk (2016) seeks to confront what he calls
“chemophobic propaganda”. Thus, the dichotomy estab-
lished by the common pattern no evidence is indicative of
a potential deadlock in scientific argumentation. If the idea
of evidence requires absolute verifiability, its scope shrinks
considerably. The fact that the collocates with evidence is
also informative in this regard. The definite article, in con-
trast to the zero marker, implies certainty and singularity.
Evidence suggests is not as forceful and monolithic as the
evidence suggests, a phrase the high frequency of which sig-
nals, like no evidence, that the concept of evidence is often
invoked when dealing in absolutes. One may also note, in
this respect, a purported equivalence between science and
evidence in parallel expressions of absolute certainty, as in
the corpus examples the science is clear (7 instances) and
the evidence is clear (9).
Other common collocates of evidence sketch a more
nuanced picture, not restricted to the yes–no or pre-
sent–absent binary: there can be much (17 instances) or
enough (17) evidence, but also insufficient (17) or little (38)
of it. The fact that the quantifiers expressing sufficiency are
often negated, as in not much evidence or not enough evi-
dence, while the main negative ones tend not to be reversed,
suggests that the quantification of evidence in most cases
implies that it falls short of confirming or supporting a given
claim (Fig.3).
Not only can evidence be quantified, but it can also be
qualified in a variety of ways: fossil evidence (22) identifies
a particular object of study, whereas empirical evidence (38)
identifies a certain method of observation. New evidence
(51) is uncovered in relation to earlier information on the
same topic, and supporting evidence (11) is expected to
back up claims to truth. An interesting category of quali-
fying adjectives concerns the specification of an affective
response, as in compelling (29) and convincing evidence
(13). Convincing is often modified by negation, as in no
convincing evidence, whereas compelling and other inten-
sifying qualifiers such as ample (14) and damning (7) are
usually employed affirmatively, as in:
There is compelling evidence that children’s percep-
tions of cigarettes are influenced by branding and that
branding detracts from the impact of health warnings
on packs. (Abbott 2013; Left Foot Forward)
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Note that the indefinite ‘there is’ does not specify where
the evidence originates. While such specification may occur
elsewhere in the article, a more impactful omission is that
of the supposedly compelled subject—in the absence of a
subject, the qualification of the evidence as compelling is
presented as an objective characteristic, thus fabricating a
tacit agreement between the author, their sources, and the
implied reader. The implication is that the evidence ‘speaks
for itself’. The representation of actors and participants is a
central issue in critical discourse analysis (e.g. van Leeuwen
2008, pp. 23–54). In scientific as well as political reports,
the responsibility of human agents is often elided, while
“agency is shifted to abstract processes and entities” (Fair-
clough 2003, p. 138). In this regard, it is also important to
take stock of the verbs of persuasion commonly found at the
N + 1 position of evidence: the evidence shows (40), indi-
cates (15) and supports (11). Together, these two patterns
(the absence of a subject and the proliferation of verbs of
persuasion in position N + 1) suggest that perspectives and
positions are seemingly automatically validated by the pres-
ence of evidence, with no need for a human mediator to be
specified as the agent responsible for interpreting the infor-
mation at hand. The most common collocate on the right-
hand side of evidence, namely suggests (59), forms part of
this widespread grammatical pattern. Often, the broader
pattern includes strong markers of emphasis that reinstate
the yes–no dichotomy at the far ends of quantification: there
are several variants of all the evidence suggests as well as
no evidence suggests. In these cases, too, the majority of
instances do not specify potentially relevant participants in
the situation of evidence assessment.5
Rhetorically charged quantifications and qualifications
such as abundant and compelling frequently precede evi-
dence, but by far the most common qualifier modifying
evidence is the seemingly more neutral adjective scientific
(197). What exactly makes evidence scientific is seldom
specified, but in some cases a number of expected charac-
teristics are explicated:
This is the first scientific evidence, published in Envi-
ronmental Research Letters, that confirms the numer-
ous anecdotal accounts. (Albert etal. 2016; Desmog)
Here, scientific evidence is partly defined by the com-
municative setting: an academic outlet is required to present
it, and it is contrasted to anecdotal accounts. The latter con-
trast implies, once again, demands of quantity and quality,
as anecdotal evidence (14 instances) is generally understood
to be gathered unsystematically and in limited amounts. Fur-
thermore, anecdotes are told rather than observed, meaning
that the scientific mode is presented in opposition to the
narrative mode of exposition. While such schemas can in
some cases be derived from the concordance lines, often the
collocation scientific evidence is simply used as a means of
emphasis, as further illustrated by the fact that the colloca-
tion is frequently preceded by additional adjectives of per-
suasion. Indeed, the most frequent pattern associated with
scientific evidence is overwhelming scientific evidence (10
occurrences). Overwhelming encodes a rhetorical mixture of
quantity and suggested affective response, and thus a merger
of the features of adjectives such as much and compelling,
discussed earlier. In addition, the phrase overwhelming sci-
entific evidence is in the majority of cases used to set up a
contrast, as in:
Despite the overwhelming scientific evidence linking
fine soot particles to premature death, Honeycutt testi-
Fig. 3 Concordance tree showing patterns preceding much evidence
in the GoK Internet Corpus (cropped). Left co-text is shown. More
common patterns are displayed in larger font. They include direct
negation of sufficient quantity via the adverb not; more extended
examples include ‘don’t provide’ and ‘neither side has managed to
produce’. See Luz and Sheehan (2020, pp. 11, 13) for more informa-
tion on the visualization tool
5 A notable exception to this overall tendency is the pattern of appro-
priation our evidence suggests (6 instances). This pattern partly inti-
mates the revelatory quality of investigative journalism, but it also
strongly suggests institutional ownership—an undifferentiated inter-
net search for our evidence will mostly return information from large
health-related research bodies such as Cochrane and BMJ.
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628 J.Buts et al.
1 3
fied before Congress that “some studies even suggest
PM makes you live longer.” (Negin 2017; UCSUSA)
Collocational patterns do not merely report a state of
affairs; they express a communicative purpose which is of
pragmatic rather than semantic importance (Stubbs 2009,
pp. 124–125). In other words, recurrent phrases are likely
to have an attitudinal or evaluative function that extends
beyond their constative value. This function is termed
semantic prosody in corpus linguistics, and in the case of
the contrastive pattern despite the overwhelming scientific
evidence, which occurs three times in the corpus, the func-
tion is not primarily to qualify the evidence in question but
to suggest that one should be surprised at the existence of an
opinion opposed to the author’s. Arguably, the various pat-
terns of linguistic modification characteristic of evidence do
not merely, or even primarily, serve to affirm, negate, qualify
or quantify, but mainly to convince the implied reader of a
given stance by rhetorical measures that conflate persuasive
and epistemic modes of expression.
Importantly for our overall argument in this paper, when
the GoK corpus is narrowed down to include only texts that
make explicit mention of evidence-based medicine, the over-
all collocational patterns associated with evidence remain
largely unchanged. Thus, the use of rhetorical adjectives
such as compelling and overwhelming is not restricted to
discussions outside the disciplinary scope of EBM, and this
broad rhetorical inflection indicates that common discursive
patterns of persuasion are shared across varied settings of
practice. The boundaries of different spheres of knowledge
production are porous, and basic concepts that display highly
frequent patterns of usage alongside more specialist applica-
tions are particularly likely to generate heated disagreements
through mutual misunderstanding. In the following section,
we show how the meaning of -based is as elusive as that
of evidence, further contributing to the fact that, while the
concept of evidence-based medicine may purportedly apply
to a restricted set of principles operational within a circum-
scribed context, this does not mean that it is necessarily
presented and understood as such by different interlocutors.
Based intheGoK Internet corpus
One of the central arguments put forward by corpus lin-
guists is that meaning does not reside in individual words,
but is realised in extended lexical elements. This means,
as already shown in the previous section, that evidence
has to be examined in its context of use. It also means that
seemingly secondary elements, such as based, are bound to
contribute heavily to the reception and interpretation of the
concept and practice of evidence-based medicine. A search
for based in the GoK Internet corpus returns 2891 concord-
ance lines. Based is a multi-faceted lexical element that can
fulfil a number of distinct linguistic functions. In order to
focus on usages that structurally correspond to the phrase
evidence-based medicine, we limit our analysis to its occur-
rence as part of a hyphenated compound adjective (as in
evidence-based), rather than as a verb (as in based on evi-
dence). However, the two variants are often closely related,
and where relevant attested verbal uses will contribute to
the argument.
For compound adjectives containing based, the Oxford
English Dictionary (OED 2020) lists four main uses. A
first common use indicates a relation to a specific location,
as in London-based (36 instances) or UK-based (33). As
these examples illustrate, such locations tend to be nations
or cities. A second general use indicates a relation to a
particular material, often described in chemical terms, and
exemplified in the corpus by compounds such as carbon-
based (10) and chlorine-based (1). The OED (2020) lists
as a third option the use of based to indicate “a foundation,
fundamental principle, or underlying basis”. This is by far
the most frequent use in the corpus, not only because of the
high frequency of evidence-based (218) and science-based
(95), but also because of the widespread use of based in
relation to social categorizations, as in class-based (36),
community-based (30), or faith-based (25). The final main
use listed by the OED concerns a specification of the base
in question, as in broad-based (20). The fact that instances
of all main categories of use can be easily retrieved from
the concordance output suggests that the corpus provides
an adequate general overview of the variety of meanings
expressed by based.
The meaning of based cannot always be intuitively
grasped by restricting one’s view to the various compounds
in which it occurs, given that these compounds themselves
form an adjectival unit that typically modifies a noun that
follows. The co-text to the right of the compound has to
be taken into account to arrive at an interpretation. A first
observation is that when the adjectival compound itself
contains a concrete material substance, the full phrase may
still establish an abstract relation, as in oil-based economy
(1) or carbon-based capitalism (1). The meaning of based
is not equivalent in carbon-based capitalism and carbon-
based vegetation (1), with the former expressing a relation
of dependency and the latter one of composition. Thus,
the interpretation of each adjective remains highly context
dependent. An observation related to this tendency towards
the abstract commonly expressed by based is the adjective’s
frequent involvement in the description of large, intangible
systems, which may be more or less regulated. The words
system and systems immediately follow based fifteen times,
and more specific examples of systems attested in this posi-
tion include taxation (7), politics (8) and organi[zs]ation(s)
(17). Social systems are composed of regular patterns of
practice, and there is a marked tendency in the corpus for
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adjectival compounds containing based to be followed by
nominal compounds containing making, such as rulemaking
(follows based 7 times), policymaking (19) and decision-
making (16, counts include hyphenated and unhyphenated
spelling variants). This is a strong collocational pattern,
as the gerundial form making seldom occurs in the corpus
without the preceding words policy or decision. In fact, the
expression evidence-based decision-making has become so
cliché that, as the following example from our corpus indi-
cates, it can be toyed with for humorous purposes:
Tom Slater has written that in order to give ‘scientific’
credibility to extending the neo-liberal state and deep-
ening social inequality, think-tanks such as the CSJ
have “mastered the craft of decision-based evidence
making, tailored to the needs of policy elites and poli-
ticians on the lookout for accessible catchphrases to
woo a jaded electorate.” (Silver etal. 2014; Discover
Society)
Typically, nouns referring to the outcome of regulatory
procedures such as policymaking can also follow based;
there are, for instance, no fewer than 55 occurrences of
policy or policies immediately following based, the bulk
of which are part of the larger pattern evidence-based pol-
icy and science-based policy. Alternatives to policy that
occur within similar patterns include approach(es) (21)
and practice(s) (8). Thus, based very frequently, and often
quite explicitly, functions to express the relation between a
productive field of practice and the principles that guide it.
This interpretation also holds for evidence-based medicine,
yet what linguistically separates this particular phrase from
its more general variants is the frequent use of an acronym,
namely EBM (38 occurrences across several articles). There
is, for instance, no acronym EBA, which could hypotheti-
cally refer to evidence-based approaches. The acronym EBP
occurs only 17 times in the corpus, and its use is restricted
to a single article (in which the P stands for policy, while
outside the corpus the same abbreviation will often refer
to practice). The use of acronyms is extremely common in
scientific writing across various disciplines, even though in
the health sciences it has been criticised as a source of “irri-
tation, misunderstanding, and even alienation” (Moris 2020,
p. 1274). Even writers who are seemingly well-acquainted
with the vocabulary involved may produce formulations that
suggest a lack of transparency, as the following example
from the corpus illustrates:
One example is the implementation of a new proce-
dure to treat asthma at the Royal Children’s Hospital
in Victoria, Australia. The EBM-based approach
was able to achieve an unusually high success rate of
95.5 percent during the first three months of transition.
(Mawby and Harris 2016; OpenDemocracy)
In the above example, the abbreviation EBM itself con-
tains the word based. Consequently, the example contains
both a pleonastic and a tautological element, with the full
formula EBM taking up the position normally reserved for
evidence. The entire framework comes to serve as a substi-
tute for the raw material: in other words, the wording may
suggest that EBM occupies a singular, unambiguous concep-
tual space. This recalls our discussion of phrasings such as
the evidence suggests in the previous section. The evidence
suggests implies access to a fully transparent, univocal data-
set, while the EBM-based approach implies access to a fully
coherent, set framework, but in both cases the assumption of
a rigid outline may be evaluated either positively or nega-
tively. The author of the example above favours EBM and
sees it as a model practice that should guide developments in
other sectors. At the other end of the spectrum, some critics
of the model characterise EBM’s rigid univocity as distinctly
malignant, as the following example illustrates:
“[EBM is not] medicine based on evidence, but the
equivalent in the field of medicine of a cult with its
unique dogma, high priest … and fervent disciples,”
says Dr. John Service, editor-in-chief of Endocrine
Practice. (Hoofnagle 2007; Denialism)
The critique presented in this quote characterises EBM as
an oppressive and disciplinary apparatus. Similar critiques
were raised in other publications, including scholarly jour-
nals, around the same time the Denialism blog post was writ-
ten. Holmes etal. (2006), for instance, argue that a focus on
EBM “eliminates some ways of knowing”, a process which
they ultimately describe as “microfascism”. This article too
is quoted several times in the corpus. Importantly, in the
quote above the speaker feels the need to unpack what he
sees as the linguistic dishonesty of EBM by questioning the
link to evidence as well as based: “[EBM is not] medicine
based on evidence”. In effect he is suggesting that the verbal
and the adjectival form of based should essentially express
the same relation. Yet, in our corpus, the phrase based on
evidence is largely reserved for unique events, decisions or
explanations, and only seldom employed with the broad dis-
ciplinary quality of the related adjectival compounds, such
as evidence-based. Disagreement on the proper application
of terms such as based is thus at the heart of the argument.
The quotes from both scholarly publications and more infor-
mal statements by specialists confirm that evidence-based
medicine has met with strong resistance for over a decade
now, while at the same time it is still presented as a model
practice for other sectors to emulate. What some see as help-
ful instructions to guarantee best practice, others interpret
as undue restrictions, and importantly, based elicits both
meanings across the corpus, not just in discussions about the
health sciences. Consider the following examples:
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630 J.Buts et al.
1 3
His book left scope for alternative views of meritoc-
racy including positive associations of merit-based
systems with social justice. (Gallinat 2018; Discover
Society)
The corruption of visa work programs might soon
expand under Trump’s immigration-reform agenda:
His administration seeks to expand “merit based”
migration of “high skill” and professional workers,
while cutting humanitarian and family-reunification
programs. (Chen 2017; The Nation)
In the first example, based connects a practice to its jus-
tification, while in the second it sceptically connects a prac-
tice to its limitations. The phrases are formally equivalent
while their evaluative purposes—partially signalled through
the use of scare quotes—are functionally opposed, as they
are in different interpretations of evidence-based medicine.
Thus, researchers seeking to untangle controversies in the
health sciences may benefit from examining discursive pat-
terns that cut across a broad range of disciplines and fields
of practice. The continued rejection of the term evidence-
based in the context of healthcare has of course not gone
unnoticed, and in recent years alternative terms have come
to circulate widely. The World Health Organization (n.d.),
for instance, explicitly states that evidence-based implies a
restricted viewpoint, and that the institution now prefers the
term evidence-informed. It is not only based that in some
contexts has fallen into disrepute. In Norwegian, the term
evidence-based is often translated using kunnskap, usually
an equivalent of knowledge rather than evidence, in part pre-
cisely to dissociate the discourse from the “positivist con-
notations that are tied to the English expression” (Bondevik
and Engebretsen 2018). Yet, in all these examples, it is not
so much the terms evidence or based that independently fall
out of favour, but rather their specific combination, as the
following example poignantly illustrates in the choice of dif-
ferent terms in parallel positions:
Ending AIDS requires evidence-informed, rights-
based global leadership (Fried 2016; OpenDemoc-
racy)
Yet are shifts in wording, such as the one from evidence-
based to evidence-informed, indicative of a correspondent
shift in practice? Positions on the subject will vary, but our
corpus suggests that while medicine may attract a variety
of modifiers such as alternative (27 occurrences before
medicine), conventional (8), modern (8) and real (8), none
offer rival paradigms to evidence-based. They may refer to a
competing outlook, but not to a competing set of principles
and correspondent practices. The rigid view associated with
EBM thus partly consolidates its continued dominance, at
least as the standard against which to argue.
Discussion
We began this article with a plea for scholars of the medi-
cal humanities to engage with a new research methodology
we believe can shed light on important aspects of the evo-
lution and contestation of a core constellation of concepts
that underpin the practice and ethos of modern medicine.
While the basic methodology of corpus-based CDA is well
established in various areas of the social and human sci-
ences, and to a much lesser extent in medicine, we set out to
demonstrate that combining this methodology with theoreti-
cal assumptions drawn from conceptual history and social
epistemology provides a powerful framework for elaborating
an ambitious research agenda. We acknowledge the largely
non-expert and diverse nature of our corpus and the need to
supplement it with texts drawn specifically from the field
of medicine. Our analysis is offered as a preliminary, pilot
study that prepares the ground for the creation and analy-
sis of large thematic corpora of expert and non-expert dis-
courses on medicine, ranging from scientific papers pub-
lished in journals such as BMJ and The Lancet to official
WHO and CDC reports, medical textbooks, as well as blog
posts and Wikipedia articles on medical topics. We hope to
begin compiling these corpora in 2021, with a view to mak-
ing them and an accompanying software interface available
to the research community as soon as practicable. Creating
such new resources can afford us novel insights into some
of the continued controversies and points of contention in
the field.
Focusing on one such point of contention, the controversy
surrounding different interpretations of EBM, we argued,
firstly, that it is in the nature of evidence as a basic concept
with wide currency in both specialist and general language
to support a variety of often conflicting meanings, and there-
fore to continue to invite contestation. We supported our
argument with an analysis of the lexical patterning of evi-
dence, followed by an analysis of based, the second com-
ponent of EBM and a modifier that may activate a range of
different, and conflicting associations. Drawing on a large
corpus of Internet English featuring articles and blogposts
written by medical practitioners, scientists, journalists and
activists of various political hues, we unpacked some of the
many meanings associated with each lexical item, high-
lighting the futility of attempting to impose a single, rigid
interpretation of what evidence-based means in the context
of modern medicine. The lexical patterns we identified had
implications beyond their use in a particular blogpost or by
a particular medical specialist or layperson. For example,
one of the patterns we identified across texts and authors is
there is no evidence of. The same pattern was documented
decades ago in an early corpus-based study as prevalent in
medical case reports, more specifically in the context of
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“eliminating unsubstantiated interpretations of a symptom
or disease in order to narrow down the potential number
of causes” (Baker 1988, p. 103). In the context of medical
journal articles, the phrase concluded a specific investiga-
tion, the steps of which could be systematically traced back
and verified. By contrast, when used in a polemical blog-
post, the boundaries of the domain covered by a declaration
that evidence is absent are not always clear, and instead of
a formulaic statement of academic expression, the phrase
becomes pre-emptive and axiomatic. This pattern may con-
vey an epistemic sense of certainty, despite no verifiable
conditions being in place to assess its situated truth value.
In other words, a speaker’s purpose determines the patterns
used, but patterns may be exchanged across different com-
municative settings, and thus fulfil different functions in spe-
cific contexts, while nevertheless retaining the semblance
of a shared argumentative value across all those contexts.
The point is not to suggest that scholarly articles are fun-
damentally more transparent than blogposts in their use of
evidence, but to elucidate why heated discussion may arise
around ways of speaking about evidence and other basic
concepts: when the same means of expression are used to
discuss different modes of practice, interlocutors’ epistemic
expectations may be violated. As both specialists and non-
specialists move back and forth across different domains and
are exposed to different interpretations of a basic concept, it
is possible that those who reject whole paradigms of knowl-
edge such as EBM may do so because they see them as
presenting either too rigid or an overly flexible interpretation
of the concept in question in relation to their own experience
of its active use in a variety of contexts. Academics and pro-
fessionals concerned with the promotion or contestation of
medical paradigms therefore cannot ignore existing notions
of evidence that circulate among different groups in society.
Our analysis also supports some of the basic presuppo-
sitions underpinning the social epistemology approach, as
outlined in our introduction. First, the lexical patterns we
identified had implications beyond their use in particular
communicative settings and across the entire social fabric.
Considering the nature of evidence as a basic concept, we
need to draw on a theoretical approach that incorporates
both scientific and lay processes of conceptualizing and
evaluating evidence. Second, examining concordance pat-
terns means that individual knowledge becomes secondary
to discursive manifestations of knowledge as a social, lin-
guistically negotiated endeavour. Third, we have found that
knowledge claims can rest, as in the case of evidence, on
attributions of sufficient quality or quantity, but that such
assessments are always subject to rhetorical techniques
of persuasion. We have also shown that elements such as
based, which may appear to be neutral or insignificant, in
fact express a wide range of divergent relations. Kvernbekk
(2011, pp. 522–524) has argued that the meaning of based
may indeed be unclear across various notions of evidence-
based practice. Our analysis has shown that conflicts of
interpretation may arise between social settings and knowl-
edge domains that alternatively understand the relation
expressed in evidence-based as one of disciplinary ties, one
of institutional embedding, one of fundamental principles, or
one of shared practices and goals. This suggests that a robust
theory of evidence-based medicine needs to account for the
values and principles that are specific to the discourse within
which claims and beliefs about evidence are articulated. As
also pointed out by other authors (Engebretsen etal. 2016),
the EBM conception of knowledge fails to acknowledge that
the way different groups engage in the process of knowing—
as unfolding in specific settings and articulated in different
types of discourse—determines the principles and objects of
their knowledge. There is a need for a situated epistemologi-
cal approach to EBM that recognizes and explains different
types of rationality, and hence plural conceptualizations of
evidence incorporating various interpretations and nuances
of meaning that circulate in the everyday linguistic environ-
ment. To develop such a theory will be one of the aims of
our future research.
Acknowledgements We would like to acknowledge the support of the
Centre for Advanced Study in Oslo, Norway that funded and hosted
our research project “The Body in Translation: Historicising and
Reinventing Medical Humanities and Knowledge Translation” during
the academic year of 2019/2020 and to thank Dr Henry Jones, Aston
University, UK, for his input into earlier versions of this article. The
corpora used in this study were created as part of the Genealogies of
Knowledge project, supported by the Arts and Humanities Research
Council Grant Reference AH/M010007/1.
Funding Open access funding provided by University of Oslo (incl
Oslo University Hospital).
Declarations
Conflict of interest The authors declare that they have no conflict of
interest.
Open Access This article is licensed under a Creative Commons Attri-
bution 4.0 International License, which permits use, sharing, adapta-
tion, distribution and reproduction in any medium or format, as long
as you give appropriate credit to the original author(s) and the source,
provide a link to the Creative Commons licence, and indicate if changes
were made. The images or other third party material in this article are
included in the article’s Creative Commons licence, unless indicated
otherwise in a credit line to the material. If material is not included in
the article’s Creative Commons licence and your intended use is not
permitted by statutory regulation or exceeds the permitted use, you will
need to obtain permission directly from the copyright holder. To view a
copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/.
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632 J.Buts et al.
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