evidence-based medicine: false friends don’t make good company
Modern methodologies to establish evidence in biomedical research were pioneered by the Canadian research group around Gordon Guyatt and David Sackett. In 1992, the term ‘evidence-based medicine’ was first used in the medical literature by Guyatt et al. [1], and in 1996, Sackett et al. [2] explained what they thought evidence-based was and what it was not. The most common, yet seriously misleading, rendering of ‘evidence-based medicine’ in German is Evidenz-basierte Medizin—a classic example of a false friend.
proof: the availability of an argument in support of the truth of a proposition
An important distinction in the philosophy of science is that between proof and evidence. Proof is the availability of an argument in support of the truth of a proposition. Certain areas of research are capable of providing such irrefutable proof. For example, the Greek philosopher–mathematicians were able to provide proof for the truth of many of their theorems, particularly in algebra and geometry.
evidence: that which we rely on in the absense of proof
In other areas of human enquiry, such as in biomedical research, there is less certainty. This is where evidence comes in. We generally rely on evidence whenever access to the truth would otherwise be problematic [3]. Evidence may be described as allowing one’s views ‘about what is the case or what ought to be done to be guided by evidence, as opposed to (say) the typically distorting influences of ideological dogma’ [3]. As (groups of ) individuals collect evidence (i.e. the results of their observations), their views will ‘increasingly converge over time: as shared evidence accumulates, consensus tends to emerge with respect to formerly disputed questions’ [3].
Evidence had formerly been taken to precede theory. For example, for Hume science relied on observations and inductive (‘bottom-up’) reasoning. This view is now generally rejected, because it is appreciated that theories—or plausible hypotheses—play an essential role in determining what type of evidence should be collected. This view is exemplified in Popper’s falsification model of science (although other models of science, in addition to disconfirming evidence, also allow for confirming evidence). In Popper’s model, science is a deductive (‘top-down’) process. Scientists formulate hypotheses that cannot be verified and confirmed, but they can be falsified and rejected—or tentatively accepted if corroborated in the absence of falsification.
To make his point, Popper used Hume’s example whereby all swans are white simply because all of the swans we have seen so far are white. There is no proof, however, that all swans are white. We can merely hypothesise that they are—and a single black swan would be enough to refute this hypothesis. In other words, if our null hypothesis is that all swans are white and we cannot reject the null hypothesis, this does not necessarily mean that the null hypothesis is true—we simply do not have enough evidence to reject it.
‘evidence’ and ‘evidenz’: a classic example of false friends
The basic principle of evidence-based medicine is that treatment be based on ‘the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients’ [2]. This evidence is provisional only. The more evidence we gather in support of a given practice, the more confidence we can have that this practice actually makes sense—but we cannot prove that it does.
‘evidence-based medicine’and ‘nachweisgestützte medizin’: an elegant pair
The German Evidenz has a fundamentally different meaning. It signifies unmittelbare und vollständige Einsichtigkeit (‘immediate and complete insight’), Gewissheit (‘certainty’), unumstößliche Tatsache (‘irrefutable fact’) [4], das dem Augenschein nach unbezweifelbar Erkennbare (‘that which is undoubtedly discernible based on what we see and perceive’) [5]. Several German-speaking authors have rightly criticised the unfortunate rendition in German for the reasons outlined above [6, 7, 8, 9] and have proposed that ‘evidence-based medicine’ be referred to as auf wissenschaftlichen Erkenntnissen begründete Medizin, auf empirisch erbrachten Nachweisen basierende Medizin, nachweisorientierte Medizin, or nachweisgestützte Medizin—all elegant paraphrases of the English original. In fact, in the presence of Evidenz, little or no ‘evidence’ is needed.
In 2000, the German term evidenzbasiert even found its way into German legislation [10], and the centre branches of the Cochrane Collaboration in German-speaking countries likewise use the translation that actually misrepresents its very mission, which is to ‘promote evidence-informed health decision-making by producing […] synthesised research evidence’ [11].
Could the cause against diluting the meaning of Evidenz have been lost already? If we agree with Werner Koller (as quoted by Anthony Pym [12]) that ‘translators are ultimately the people who say what should or should not be proposed to the receiver as an equivalent’, let us take to heart Hans-Martin Gauger’s plea in Forum Sprachkritik of the Deutsche Akademie für Sprache und Dichtung: ‘Trennen also, bitte, zwischen Evidenz einerseits und Beweis andererseits. Oder retten wir unsere, sagen wir, kontinentale Evidenz. Sie ist ein semantischer Reichtum’ [6].
references
[1] Guyatt G, Cairns J, Churchill D, Cook D, Haynes B, Hirsh J, et al. Evidence-based medicine. A new approach to teaching the practice of medicine. JAMA 1992;268:2420–5. [2] Sackett DL, Rosenberg WM, Gray JAM, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ 1996;321:71–2. [3] Kelly T. Evidence. The Stanford Encyclopedia of Philosophy 2008, Edward N. Zalta (ed.). [4] Duden online: Evidenz. [5] Wikipedia: Evidenz. [6] Gauger H-M. Evidenzbasierte Medizin. Das Forum Sprachkritik der Deutschen Akademie für Sprache und Dichtung. [7] Weber J. Evidence based dentistry. DentalWorld 2005;23/24:9–11. [8] Wolf-Diedrich. Evidenz: Sinnwidrige Übersetzung. Deutsches Ärzteblatt 2000;97(21):A–1416. [9] Graebsch C. What works? – Nothing works? – Who cares? ‘Evidence-based Criminal Policy’ und die Realität der Jugendkriminalpolitik. In: Dollinger B, Schmidt-Semisch H, editors. Handbuch Jugendkriminalität. Kriminologie und Sozialpädagogik im Dialog. Wiesbaden: VS Verlag für Sozialwissenschaften, Springer Fachmedien Wiesbaden GmbH; 2011. p. 137–4. [10] Deutsches Sozialgesetzbuch (SGB). [11] The Cochrane Collaboration: About us. [12] Pym A. Translation and text transfer: an essay on the principles of intercultural communication. Frankfurt am Main: Verlag Peter Lang Internationaler Verlag der Wissenschaften; 1992.
this text first appeared in medical writing 2014;23:154–60 as part of an assay on equivalence in translation.