Summary of the impact

Loughlin's research criticises the drive towards impersonal decision-making procedures across a range of professional practices, aiming to revive approaches placing the cultivation of the virtues, of sound judgement, at the centre of all practical discussion. It has empowered opponents of formalism in management and policy, and scientism in medical practice. This case study concerns Loughlin's identification of the limitations of Evidenced-Based Medicine (EBM), and development of an alternative, evidence-informed approach. Loughlin has communicated his research beyond a narrow academic audience, to a wide range of professional groups, triggering a growing recognition of the need for a humanist, person-centred alternative to EBM. Practitioners and patients alike benefit from the requirement to frame all debates about good practice with reference to the understanding that the parties to the clinical encounter are persons.

Underpinning research

Loughlin has worked at MMU since 1992, as a lecturer, then (since 2004) a Reader. The research underpinning this case study is his work exemplifying and promoting methods of analysis derived from philosophy to clarify complex problems of policy and practice, addressing foundational questions about management, professional ethics, moral education, research methodology (in applied philosophy and social science), and the relationship between knowledge, judgement and evidence in medicine. A core philosophical concern in his work is the centrality of the normative in all practical discussion. Discussion of professional practice aims to produce evaluative conclusions, regarding what persons (acting in professional capacities) should do. Yet background assumptions associated with scientism cause us to search for impersonal mechanisms, rather than returning to discussions about intellectual and moral virtue, and what makes a person a good decision-maker in specific instances.

From January 1993 to date, Loughlin has published a large number of influential essays in highly esteemed international professional/medical journals including: Health Care Analysis; The Journal of Evaluation in Clinical Practice (JECP); Journal of Medical Ethics;Philosophy, Psychiatry and Psychology;Philosophy of Management; European Journal of Person-Centered Healthcare. He co-authored the influential editorials of the JECP's widely read annual `EBM-thematic' issues (widely credited with being the focus for developing an alternative approach to EBM) from 2006 to 2011 - his other co-authors being senior medical researchers and practitioners. The most recent of these much-cited editorials argued for a move from EBM to Evidence-Informed Medicine (EIM). In 2010 he edited the first ever thematic issue of a primarily clinical journal devoted entirely to the philosophy of medicine, discussing the nature of evidence, clinical judgment and broader questions of medical epistemology. On publication of the fourth of these internationally acclaimed JECP `philosophy-thematics', including papers on virtue epistemology and its applications to clinical reasoning, he was appointed Associate Editor of the journal, making him one of the few philosophers in the world to occupy so senior a role in a major clinical journal.

In 2002 he published a monograph, Ethics, Management and Mythology [1]. This study criticised the role of management theory in undermining professional autonomy and raised methodological questions about quality measures, bioethics and the use of evidence in health policy. It examined the problems of applying scientific theory and methods to policy issues and organisational decision-making. Its criticisms of Total Quality Management and Quality-of-Life measures (employed by bodies such as the National Institute for Clinical Excellence) provided the basis for his 2001 address at LSE to launch the journal Philosophy of Management (then Reason in Practice) and were developed further in his 2004 article in the same journal on `Management, Science and Reality'.

A key concern is use of empirical data to establish normative conclusions [4,5]. EBM's reliance on statistical methods of analysis is logically inadequate to bridge the gap between information and evidence adequate to establish conclusions about the right course of action in a specific and potentially unique case [2, 3]. Approaches founded on unapologetic discussion of the value of medical practice place the concept of good judgement at the centre of practical enquiry, rather than relegating judgement to `opinion' with a low evidential status, as in successive `evidence-hierarchies' [1,2,3,6]. The work on the limits of scientific explanation [4,6] are also part of a broad philosophical critique of scientism that informs opposition to reductionist approaches such as EBM.

The background to the 2002 monograph [1] was the `Critique' series of articles commissioned by David Seedhouse when setting up the journal Health Care Analysis. The aim of the series was to take management and government documents regulating or `guiding' practice in health areas, and subject them to philosophical critique. On the basis of the reaction to the series Loughlin was invited to address professional groups, and Nigel Laurie invited him to speak at the launch of the journal now called Philosophy of Management and Andrew Miles commissioned several articles for the JECP. Miles is a major figure in the world of public health and runs a number of international organisations (including the European Society for Person-Centred Healthcare). Loughlin joined Miles and a group of practitioners and intellectuals including Ross Upshur, Steven Buetow, Mona Gupta and Mark Tonelli arguing against the then dominant EBM movement. Loughlin co-authored papers with them, and helped to organise and attended conferences to disseminate the ideas to practitioners.

References to the research

Research Grants:

October 2004: Grant provided by School of Medicine and Dentistry, Queen Mary College, University of London (£4,000). The grant was awarded to work on collaborative research in the School and internationally to produce articles for a special edition of the Journal of Evaluation in Clinical Practice on EBM, and to design a Critical Thinking component for the School's MSc in Primary Care. The published results of the collaborative work were published in three jointly authored articles in the Journal of Evaluation in Clinical Practice.

Details of the impact

Loughlin's research has had a major impact within the healthcare community, influencing the thinking of practitioners, service-users and the broader public. It has been instrumental in enabling an appreciation of the philosophical limitations of EBM, making an important contribution to the emergence of EIM (allowing practitioners and academics to consider different ways of framing practical problems); to the revival of the idea of Person-Centred Medicine and a new dialogue between traditional defenders of EBM and its critics - exemplified in the debates between EBM-theorist Jeremy Howick and prominent practitioner and EBM-critic Mark Tonelli, that Loughlin organised as editor of the JECP philosophy-thematic issues. (Tonelli, a major force in medical education in the USA, credits Loughlin's "original work and commentary" as having "been central in forcing the evolution of EBM over the last two decades" and he notes that Loughlin "has been instrumental in shining the bright light of philosophical analysis upon the assumptions underlying the EBM movement, revealing the poorly constructed framework for a claim that the results of clinical research should be prescriptive in the care of individual patients". This work has been of benefit to practice because "Very few philosophers have both the willingness and the ability to take their case to the right audience, often people who feel they have very little use for philosophy. But for ideas and arguments to matter, they need to be presented to those with the ability to make change.") The underpinning research is embedded in the impact activities. By linking the debates about EBM with the quality movement and other policy initiatives, Loughlin has "at once located the issues beyond medicine while showing their impact at the daily level of clinical practice" [C]This work has been characterised as an "international level intervention" benefitting patients and practitioners by moving the debate about practice away from "the framework of scientistic reductionism" to one framed by the significance of the personhood of both parties to the clinical encounter [A]. His analyses have paved the way for significant policy developments including the recent revitalization of Person-Centred Medicine, a development recognised by the World Health Organisation as a "major shift in thinking" on the global stage, and which could not have been achieved "without the philosophically practical examination of EBM which internationally eminent scholars like Loughlin have led for over a decade" [E]. As such the work has had "unprecedented influence across many health professions and academic disciplines achieving both inter-professional and trans-disciplinary significance" [D]

Loughlin has been committed to disseminating his research beyond the community of philosophers, communicating ideas and arguments to practitioners through healthcare journals, conferences and addresses to professional bodies. During this Impact period he has presented more than 40 papers at conferences and professional gatherings, to groups as diverse as dentists, psychiatrists, social workers, NHS quality-improvement organisations, osteopaths, educationalists, GPs and construction managers. He has been invited to head-to-head debates with the NHS Head of Clinical Governance (before a 300+ audience of senior NHS staff at the Royal College of Physicians) and the Vice-President of the Royal College of General Practitioners. He was invited to give a major address to the prestigious Istituto Superiore di Sanita in Rome, to an audience including a diverse range of senior health staff and officials, where fellow speakers included the Head of the Italian Cochrane Association (later published as [3]). He persuaded the British Association for the study of Community Dentistry to reject (overwhelmingly) the motion that quality- of-life measures should provide the basis for commissioning local dental services in the UK, in a head-to-head debate with a leading designer of dental QoL measures (debate hosted by the Royal College of Physicians). On the basis of this presentation he was invited to assist the Royal College of Surgeons in designing and delivering its postgraduate programmes on health policy and leadership, and his work is credited with having "stimulated debate, helped clarify thinking and in doing so, helped advance healthcare policy at numerous levels" [B]. He has reached a wider, public audience by giving radio interviews and writing for more populist publications than the academic journals cited above, including the Times Higher Education Supplement (full page article),The Philosophers Magazine and the online Scope Magazine on the need for a proper philosophical understanding of our current professional, health and social problems.

Loughlin has made a significant impact on scholarship at the British School of Osteopathy (BSO) and through that institution, the osteopathic profession. The starting point in the early 90s was the supervision of Stephen Tyreman's PhD thesis, which applied philosophical analysis to osteopathic practice to elucidate the meaning of key ideas within osteopathy. This, the first doctoral-level work to come out of osteopathy, was then used to develop the undergraduate degree. (Stephen Tyreman, is now a Professor and Dean of Osteopathic Education Development, and also Course Leader for the Professional Doctorate in Osteopathy (Validated by University of Bedfordshire) at the British School of Osteopathy in London.) Since then Loughlin has continued to be involved with the BSO as an external examiner, where he supported the integration of philosophy into the pre- registration qualification award. He later was a visiting contributor to postgraduate programmes, where he supported the development of critical analytical thinking and more recently he has made a major contribution to the new Professional Doctorate programme in Osteopathy. His work on the limits of scientism [6] has been included in this doctoral programme and forms the basis for a defence of osteopathic understandings of evidence in the wake of renewed attacks on the discipline from EBM-protagonists.

As a result of his work Loughlin was invited in 2010 to co-author the Policy Statement on Evidence for the Science Advisory Council of the College of Medicine, a version of which is on its website and summarised in its launch document: http://www.collegeofmedicine.org.uk. (He is the only philosopher to have been invited to join its Scientific Advisory Committee.) Loughlin is a regular contributor to the postgraduate programmes in the Faculty of General Dental Practice in the Royal College of Surgeons, and has helped develop postgraduate provisions for health professionals in London, Bath and Buckingham, where he was awarded the title of Visiting Professor in Philosophy as Applied to Medicine, and addressed international audiences of postgraduate medical students.

He has long-standing links with many organisations working in health and social care. In 2011 he addressed European Association of Schools of Social Work conference on ethical reasoning in the context of an irrational world, discussing the migration of the concept of `Evidence-based practice' from its origins in medicine to such areas as social work practice. He was one of two philosophers invited to the First UK Meeting of the International Network of Person-Centred Medicine, which functions under the direction of the World Health Organisation, World Psychiatric Association, Word Association of Family Doctors, World Federation of Medical Educators and World Association of Patients' Associations. In 2013 he addressed an international conference for health professionals, policy-makers and researchers in Geneva, organised by the Network . He has been invited to Chair the Special Interest Group for Health Philosophy in the new European Society for Person-Centred Healthcare. With the Society's CEO he is organising (in collaboration with the Medical University of Plovdiv, Bulgaria) a series of training sessions in delivering Person-Centred care with medical practitioners from across Europe.

Sources to corroborate the impact

Full statements available from (full details submitted separately into the submission system):

[A] Professor, College of Medicine, Guys Hospital, London, SE1 9RT corroborating international impact on patients and practitioners.

[B] Board Member, FGDP(UK), Royal College of Surgeons, London WC2A 3PE corroborating impact on healthcare policy.

[C] Psychiatrist, Centre Hospitalier de l'Université de Montréal, 1058 rue Saint Denis, Montréal, Québec, H2X 3J4, Canada corroborating impact on practice.

[D] Canada Research Chair in Primary Care Research; Professor, Department of Family and Community Medicine and Dalla Lana School of Public Health, University of Toronto, Ontario, Canada corroborating influence on interdisciplinary healthcare professions.

[E] Associate-Professor, Department of General Practice and Primary Health Care, University of Auckland, Auckland, New Zealand corroborating impact on the revitalisation of person centred medicine.