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This chapter recounts the emergence of orthodox medicine. Medical care and medical education emerged as a scientific enterprise in the last quarter of the nineteenth century, with the help of the advances in germ theory, anti-septic techniques, hygiene, anesthesia, and surgery. By the turn of the twentieth century, orthodox medicine succeeded in eliminating a number of unconventional therapies, challenging philosophy-based practices through “evidence-based medicine” (EBM). Biomedicine treated disease as a biochemical phenomenon that could be classified into discrete categories of causation using standardized, objectified, and technologically validated biochemical treatments and mechanisms. This led to the evolution of clinical trials, such as the blind or masked (placebo) assessment; the double-blind, placebo-controlled randomized clinical trial (RCT); and the so-called Cochrane Collaboration, which incorporated meta-analysis to support RCT's predictions.

Evidence-based medicine is clinical care guided by the best-available scientific evidence generated from clinical research linked with the clinical acumen of the individual physician. It is built upon the principles of clinical epidemiology, and requires the physician to collect valid, reliable, and complete data from the patient, and in turn, use external evidence from clinical research to guide the patient’s care. Ways have been developed to help doctors deal with the explosion in the volume of clinical literature, evaluate the quality of individual studies, synthesize evidence from multiple studies addressing the same clinical question, and judge the applicability of the literature to the individual patient at hand. Methods have also been developed for the creation of clinical practice guidelines, but such guidelines can be undermined by financial conflicts of interest. The greatest challenge, however, is in getting physicians and patients to apply the evidence in clinical practice.

This chapter deals with the development of knowledge which is to be applied in order both to understand what works and to show what has worked — with the improvement of practice and policy and with claims for competence in the development of solutions to the problems of contemporary life — the policy domain, and in the implementation and execution of those policies, the practice domain. It refutes the arguments presented in particular by the Cochrane Collaboration for health, but also with some qualifications endorsed by the Campbell Collaboration in relation to general policy, that is meaningful to construct a hierarchy of modes of production of evidence with the meta-analyses of randomized controlled trials occupying the highest position in that hierarchy. It then considers the issue of variables versus cases by taking forward the complex realist methodological arguments developed in Chapter One.