Saturday August 19, 2006
“Deconstructing the evidence-based discourse in health sciences: truth, power and fascism.” Even from looking at the title, you just know this academic paper, from the September edition of the International Journal of Evidence-based Healthcare, is going to be a corker. And it uses the word “fascist” (or elaborate derivatives) 28 times in 6 pages, which even Rik Mayall in the Young Ones might regard as over-egged.
Now obviously post modernist intellectuals are about a thousand times more intelligent than me – because I only know about science and computers – but I found this paper so confusing I thought it might be a spoof. After all, who could forget the great Sokal hoax, where a professor of physics at NYU submitted “Transgressing The Boundaries: Towards A Transformative Hermeneutics Of Quantum Physics”, a deliberately meaningless joke article purporting to undermine his own discipline, to Social Text, a leading journal in the field, and had it accepted and published, to universal delight?
But this is very real, very turgid, spectacularly offensive, and characteristically, completely misunderstands its target. Here’s what they put in the “objectives” section of their abstract: “The philosophical work of Deleuze and Guattari proves to be useful in showing how health sciences are colonised (territorialised) by an all-encompassing scientific research paradigm – that of post-positivism – but also and foremost in showing the process by which a dominant ideology comes to exclude alternative forms of knowledge, therefore acting as a fascist structure.”
Let me put my fascist cards on the table and point out right up front that these are not “objectives”. Although of course, academic woolliness goes with the territory. In case you haven’t heard of their quoted authority, the continental philosopher Felix Guattari, here is a quick quote from his other work which I think betrays an admirable clarity: “We can clearly see that there is no bi-univocal correspondence between linear signifying links or archi-writing, depending on the author, and this multireferential, multi-dimensional machinic catalysis.” Perhaps Gilles Deleuze is more your cup of tea: “In the first place, singularities-events correspond to heterogeneous series which are organized into a system which is neither stable nor unstable [Jesus], but rather ‘metastable’, endowed with a potential energy wherein the differences between series are distributed.”
These characters are being recruited to attack the notion of evidence based medicine, and the argument of this paper – bear in mind it’s not an easy read – seems to be that: evidence based medicine rejects anything that isnt a randomised control trial (which is untrue); the Cochrane Library, for some reason, is the chief architect of this project; and lastly, that this constitutes fascism, in some meaning of the word they enjoy (28 times).
Here’s a flavour. “The classification of scientific evidence as proposed by the Cochrane Group [sic] obeys a fascist logic. This ‘regime of truth’ ostracises those with ‘deviant’ forms of knowledge. When the pluralism of free speech is extinguished, speech as such is no longer meaningful; what follows is terror, a totalitarian violence.” They bang on about Newspeak. At one point they seem to identify epidemiologists with George W Bush. And so on.
Now firstly, they are plain wrong about the Cochrane Library (which simply produces good reviews of published literature): it does not only use trial data, as they claim, and it is spectacularly ignorant of them to suggest otherwise.
But there is a more important general issue here. Evidence based medicine is widely perceived as being soul-less, and algorithmic: the last thing we’d want from doctors. This is a foolish misunderstanding. EBM is about using quantitative information, in concert with all other forms of knowledge, sensibly, in a clinical context. It does not denigrate other forms of knowledge, like clinical experience or patient preference. It is not about being an automaton. I believe you humanities graduates would call that a straw man argument.
That’s all a bit sensible: how about some more childish attacks, ideally involving fascism? Okay then. I will wear their label of “fascist” with a cheeky grin. But Archie Cochrane, on the other hand, pioneering epidemiologist, inspiration for the Cochrane Library, a prisoner of war for four years in Nazi Germany (“the main reason for my capture was my inability to swim to Egypt”) who has, from his abstracted position, probably saved more lives than any single doctor you know, might see it a little differently, since in 1936, he dropped out of medical school and travelled to Spain to join the International Brigade, where he fought genuinely violent totalitarian oppression, the fascists of General Franco, with his own two hands. Now. What did you do with your summer holidays?
Archie Cochrane (left, with stylish Spanish gentleman) as a captain in the International Brigade c.1936.
You can read the full paper here.
And while I’m in the mood for some links, here is an example of a Cochrane review, one of the most famous in fact, which includes an awful lot more than just “trials”, demonstrating how phenomenally ignorant the authors of this dismal social science piece were about evidence based medicine. I’m not going to re-read this Cochrane review right now, but it’s perfectly possible, given the question they were examining, that amongst the many other forms of data in there they may not actually have cited a single “trial”. Innumerable other Cochrane reviews will be similar in that regard.
Oh, and the ex-head of NIH favourably quoted the Holmes microfascism article recently.