Criticism of Evidence-Based Design
Note: This is a draft excerpt taken from an upcoming essay on Evidence-Based Design in the context of Modernism, as well as a architectural intervention on the Oberlin Student Health Center.
The topical importance of healthcare today reinforces the need for more medical facilities in the future. Undoubtedly, the framework of evidence-based design will be integrated into many foreseeable healthcare spaces. However, is evidence-based design the most successful method for healthcare design?
Several factors shade the nascent field of evidence-based design as debatable in effectiveness at best, and completely inadequate at worst. Primarily, the modern hospital environment, as a program, does not differ greatly from ancient and spiritual healing spaces, which were built without medical evidence and were effective for medical care. Secondly, the design of healthcare environments does not differ in practice from the practice of architecture in general. Thirdly, few studies exist supporting the link between the environment to patient well-being. Lastly, evidence-based design is often utilized by architects to market themselves and enforce a ‘progressive’ image.
Though formal styles and visceral elements have changed, the modern hospital does not differ greatly in overall purpose from the ancient healing spaces of the Greeks and Monastic Infirmaries of the Middle Ages. In the ruins of several ancient hospitals, the concept of “in-patient” and “outpatient” wards is often observed. These environments were designed without the advantage of medical evidence and attained high-levels of significance, similar to a temple or sacred space.
For example, the “Sanctuary of Aesculapius” (of which, hundreds of physical iterations across the Mediterranean exist) of Albania had services, including priests, musicians, and nurses. Patients were given a ritualistic soul cleansing, slept in an outdoor space dedicated for patient incubation, and were entertained by theatre. Though the efficacy of this architectural environment is unknown (despite claims of supernatural cures), it was undoubtedly constructed without scientific evidence. This is an example of the excessive prominence given to evidence-based design.
If it can be inferred that any architectural intervention, ancient or not, is designed to provide comfort, shelter, and interior space as a primary function. A hospital environment should not differ from this primary purpose. Eero Saarinen said that “the purpose of architecture is to shelter and enhance man’s life on earth and to fulfill his belief in the nobility of his existence.” Why should the principles of design change today for hospital environments? In their book, entitled “Learning from Las Vegas,” Robert Venturi and Denise Scott Brown support this question and observe that “the creation of architectural form was to be a logical process…determined solely by program and structure, with an occasional assist…from intuition.” As Venturi and Scott Brown suggest, architectural design principles are strong enough remain constant in all facets and programs of design without supplementary material. Used in the context of hospital environments, Venturi and Scott Brown diminish the need for evidence-based design, in favor of traditional architecture practices applied to the hospital environment.
As a new field, evidence-based design offers few studies to base a design intervention on. Professor Roger Ulrich observes only approximately 600 studies in evidence-based design that connect the effectiveness of a healing space to patient well-being. Such a few number of evidence-based design studies does not amount to a fundamental base on which to evaluate or construct with assurance of results. Therefore, most ‘evidence’ is purely anecdotal and offers only an empirical, case-by-case verification of a given study (Stankos).
Eminent Professor William Hillier of the University of London Department of Architectural and Urban Morphology characterizes architectural design as reliant on two components: “the precedent” and “theoretical principles.” As an element of architecture, the precedent accounts for half of the approach to design according to Hillier. The medical and evidence used as a precedent for evidence-based design is flimsy at best and, as a body of research, is a poor precedent for the design of a healthcare spaces. In response to natural elements used as a formal precedent in evidence-based design: this is in no way a new movement. Incorporating natural elements has been part of design in the past and does not represent a new way of thinking about architectural design (Wagenaar).
Lastly, evidence-based design enhances an architect’s marketability and image. As Professor Mary Stankos suggests in her article Evidence-Based Design in Healthcare: A Theoretical Dilemma (University of Missouri-Columbia), the concept of evidence-based design is a “polemic” — a verbal or written argument — which asserts itself as ‘better’ than the current practice. In a similar vain, evidence-based design resembles the “LEED” program’s somewhat pretentious striving for attention in ecological design.
Clearly,the practice of evidence-based design has flaws, such that even proponents acknowledge the lack of agency in the field. Firstly, as illustrated through the historical precedent of the Sanctuary of Aesculapius in Albania, an effective healing space can be constructed without evidence-based design and have been for hundreds of years. Secondly, the architecture of healthcare environments does not differ from the canon of architectural design. Thirdly, if the nature of architecture is fundamentally based on the precedent as Professor Hillier suggests, and limited supply of actual projects and research exists, evidence-based design cannot truly be an effective predictor of success. Lastly, evidence-based design can be used as an architects’ marketing tool. These four factors contribute to criticism of evidence-based design.
-C.S.
