實證醫學中的科學證據：證據階層的實作與科學哲學觀點

How to Stratify Scientific Evidence: Accessing the Hierarchy of Evidence in Evidence-Based Medicine

科學證據在科學實作與決策中扮演相當重要的角色，同時實證醫學作為科學中循證實作的代表，其基本原則之一為強調證據階層的重要性。當代科學哲學對此多有批評，對證據階層的概念加以駁斥。本文詳析實證醫學的證據觀點與科學哲學中的證據實用主義，提出以證據行動者和證據目的導向的討論原則，透過將行動者與目的導向進行區分，將實證醫學與證據實用主義進行分類，將根據方法學評價的證據階層歸類為「證據製造者—結論導向」觀點下的產物，同時強調證據使用者的決策導向之目的適切性可更加彰顯實證醫學的「問題解決」的實作精神。

This paper examines the hierarchy of evidence originating from evidence-based medicine and the dominant view among evidence-based practices across disciplines. Philosophers and practitioners have proposed several accounts to modify the hierarchy and challenge the criteria for stratifying evidence according to the methods by which they are derived. By way of reviewing and commenting on the existing accounts of evidence, we suggest a classification of evidence by distinguishing between the relevant actors as evidence users and producers, and their purposes as decision- or conclusion-oriented. While the traditional hierarchy of evidence is characterized by an evidence producer-decision-oriented approach, evidential pragmatism in the philosophy of science takes an evidence user-conclusion-oriented approach, and evidence-based medicine an evidence user-decision-oriented approach.