It’s a Trick, Right?
Ohhhhhhh lordy. Look at this. It’s called ‘Deconstructing the evidence-based discourse in health sciences: truth, power and fascism.’ Isn’t that just the best title? But the content is even better.
Drawing on the work of the late French philosophers Deleuze and Guattari, the objective of this paper is to demonstrate that the evidence-based movement in the health sciences is outrageously exclusionary and dangerously normative with regards to scientific knowledge. As such, we assert that the evidence-based movement in health sciences constitutes a good example of microfascism at play in the contemporary scientific arena.
Microfascism! Yelp! What will happen when those evidence-based movement bastards turn to macrofascism? Will they get even more outrageously exclusionary and dangerously normative on our asses? Or will they just kill us? Let’s ask Deleuze and Guattari; they’ll know.
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.
But what if it’s a Deleuzoguattarian ideology that is dominant, does it exclude alternative forms of knowledge and thus act as a fascist structure? I bet I’m not supposed to ask that question, am I. I have to go sit on the microfascist stool for four minutes.
Because ‘regimes of truth’ such as the evidence-based movement currently enjoy a privileged status, scholars have not only a scientific duty, but also an ethical obligation to deconstruct these regimes of power.
You understand, don’t you? It’s clear, isn’t it? Dominant ideology excludes alternatives and it enjoys (whee! woopah! heehee!) privileged status so it’s a regime of power and a fascist structure. The only liberatory and truly fair thing to do is to have evidence-free health science; that’s an ethical obligation.
This thing is so ridiculous that it’s hard not to suspect it’s another Sokal hoax. Hey – [tap tap] – are you another Sokal hoax? Hello?
“Evidence-free health science”
How liberating! We will all be free…to die.
How would an “evidence-free” consultation with your GP go?
Patient: I don’t feel to good.
GP: Try some of this macrobiotic herbal tea!
Patient: But you haven’t even asked what’s wrong with me? Or done any tests!
GP: Ah, no! But I have an ethical obligation to ensure that no particular form of knowledge occupies a privileged status with respect to alternatives. Investigating your symptoms, particularly with invasive western technology, would create a fascistic and exclusionary ‘regime of truth’ whereby alternative ‘truths’ were devalued and marginalised.
Patient: What about this herbal tea, then, does it work?
GP: Certain native tribes believe very strongly in its efficacy.
Patient: Has it been tested?
GP: Belief in empirical evidence over alternative ways of knowing is outrageously exclusionary. Try the tea. If it works for you, then it works for you. There is no need for you to have this belief ‘validated’ by privileged fascitic white males in laboratories.
Patient: I’m leaving.
GP: But you haven’t paid your bill!
Patient: I *believe* I have. I don’t see why *your* view should be privileged over mine.
You know, I’m really starting to lose patience with these idiots – why can’t they all be ‘late’? Maybe it’s because I’ve rediscoverd the Two Percent Company blog; I think their attitude might be starting to rub off on me. They are much less diplomatic than B&W.
I can almost empathise with the right-wing pundits who constantly harp on about liberal academic elites – they’ve got a point when it comes to the likes of these guys.
Oh, heavens. It wouldn’t be macrobiotic herbal tea — that’d be cultural appropriation, tsk tsk. It’ll be anti-depressants that the doctor will be foisting on you.
Which is exactly what’s been happening in the last few years to a fair number of my acquaintances in HMOs. You can have anything from an autoimmune disease to a pinched nerve — if your blood sugar is at a reasonable level and you don’t have an arm hanging off, it’s Prozac for you, at least until you come back and complain a while.
When I read your piece, I felt certain that the paper was written by academics in nursing. Guess what?
This sort of thinking, and other sorts of drivel such as “therapeutic touch”, is pervasive in academic nursing departments.
Having made my point about academic nursing, I should say that I think there are valid criticisms to be made about the Evidence-Based Medicine movement. The very name they’ve given themselves does itself create a sort of barrier to argument, and that point has been made by many physicians who dispute their methodology and conclusions.
The idea that EBM is becoming an “exclusionary and dangerously normative” mindset is actually not that unusual among medical researchers, and to some extent the authors have a valid point. But they underestimate the extent to which EBM is controversial within medicine itself. And rather than attacking EBM on scientific grounds, using specific examples, the authors prefer to float in a sphere of abstraction, where just invoking the names of Deleuze, Guattari, Derrida, Lyotard and Foucault appears to constitute some kind of argument. Unfortunately Foucault was a far superior thinker to most people who cite him as an authority.
There is a critique to be made of EBM and its institutional and political influence, but this sophomoric paper isn’t it.
One of these two articles is a definitely a spoof. The other just looks that way:
“There are many natural scientists, and especially physicists, who continue to reject the notion that the disciplines concerned with social and cultural criticism can have anything to contribute, except perhaps peripherally, to their research…………Rather, they cling to the dogma imposed by the long post-Enlightenment hegemony over the Western intellectual outlook, which can be summarized briefly as follows: that there exists an external world, whose properties are independent of any individual human being and indeed of humanity as a whole; that these properties are encoded in “eternal” physical laws; and that human beings can obtain reliable, albeit imperfect and tentative, knowledge of these laws by hewing to the “objective” procedures and epistemological strictures prescribed by the (so-called) scientific method.”
Alan D. Sokal: “Transgressing the Boundaries: Towards a Transformative Hermeneutics of Quantum Gravity.”
“Those who are wedded to the idea of ‘evidence’ in the health sciences maintain what is essentially a Newtonian, mechanistic world view: they tend to believe that reality is objective, which is to say that it exists, ‘out there’, absolutely independent of the human observer, and of the observer’s intentions and observations. They fondly point to ‘facts’, while they are forced to dismiss ‘values’ as somehow unscientific. For them, this reality (an ensemble of facts) corresponds to an objectively real and mechanical world. But this form of empiricism, we would argue, fetishises the object at the expense of the human subject, for whom this world has a vital significance and meaning in the first place. An evidence-based, empirical world view is dangerously reductive insofar as it negates the personal and interpersonal significance and meaning of a world that is first and foremost a relational world, and not a fixed set of objects, partes extra partes.”
Dave Holmes et al., “Deconstructing the evidence-based discourse in health sciences: truth, power and fascism”
Tony, I agree with what you said, but I’m not sure I agree with what you meant.
The Sokal hoax is spoofing people who dispute a realist approach to the physical sciences.
The Holmes et al piece is attacking those who (as they see it) want to treat the practice of clinical medicine as if it were one of the physical sciences, with the same realist implications.
Despite the similarity in language, I don’t think these two excerpts you’ve provided have anything in common. What pisses me off about Holmes et al is that it might lead some people to think that a critique of EBM amounts to a critique of the scientific method à la Sokal, and that’s nonsense.
Clinical medicine is not a science. It is a practical discipline which deals with individuals. It utilizes techniques developed by, and discoveries made by science, but it is not itself a science.
To give an example, there is a tendency in the EBM world to treat RCTs as if they represented a kind of epistemological gold standard (even though they may say they don’t, they do, which is why I say examine their methodology carefully). But if an RCT shows that only 5% of patients with X respond to wonderdrug, and you have X, what does that tell your physician about the probability you will respond to wonderdrug? EBM practitioners often seem to be operating with realist background assumptions – that there is a correct answer to the question, and RCTs can provide it. This is (or ought to be) Holmes’ point. Maybe you don’t have much in common with the population studied in the RCT. Maybe you appear to have a lot in common, but you actually have (unknown to anyone, including your physician) a biologically-determined predisposition to respond favourably to the drug. Maybe you don’t, but you’re 35 years old with 3 kids and wonderdrug is your last hope. How does the RCT help you, your physician, and the people paying for your treatment decide what is best in your case?
There are indeed powerful political and institutional interests backing EBM. And to the extent that OB can jokingly say something like “The only liberatory and truly fair thing to do is to have evidence-free health science” does show that EBM, apparently just by virtue of its name, really has gained a privileged status. Critics of EBM typically dispute EBM’s notion of what constitutes evidence, not the need for evidence in medical decision-making.
Hi Antirealist,
Like OB, when I first read the paper by Holmes et al., I thought it was a Sokal-style hoax – hence the quotations. Well apparently it isn’t a hoax, and so I assume they are trying to make a serious point. Now it’s true that if you grit your teeth, re-read the article carefully and try hard, you can (sort of) see what they’re trying to get at, and I don’t disagree with your interpretation. Indeed, your comments do a good job at distilling down the essence of their argument. But for goodness sake, why didn’t they make their case with similar clarity instead of this pretentious and absurdly balletic prose style? A prose style incidentally, that was so ruthlessly parodied by Sokal.
Hmm. “Well apparently it isn’t a hoax, and so I assume they are trying to make a serious point.” Not a safe assumption, I think. antirealist is saying there is a serious point to be made, but not really that Holmes et al. are making it. It doesn’t look to me as if they are saying the same thing antirealist is saying – it looks to me as if they are making a much larger claim. They would, for instance, surely reject antirealist’s “techniques developed by, and discoveries made by science”, or at least say something heavily skeptical and “deconstructive” about them. I think the problem goes well beyond mere style, and into substance.
On the other hand, antirealist has set me straight; I didn’t know about these non-absurd critiques of EBM, and clearly ought to before I mouth off.
I think that OB had it right the first time. I read the paper. There may indeed be issues with EBM but it doesn’t seem to me as if Holmes knows what they are.
In fact what I read Holmes as saying is that _any_ body of expertise — say the collective wisdom of golf pros on how to grip the golf club (yes, such issue weighs heavily on me these days) — is suspect because it leads to “privileging” one view over another. Ugh.
Yeah, that’s what I read them as saying too (even if there are issues with EBM). The Andrew Ross school of thought, one might call it. Andrew Ross makes an appearance in Why Troof, and I’ve made some fun of him here, too. There is his quotation in ‘Quotations’ for example…
“How can metaphysical life theories and explanations taken seriously by millions be ignored or excluded by a small group of powerful people called ‘scientists’?”
That’s pretty much what that article is saying – note the word ‘excluded.’ This is classic stuff.
(Good luck with the grip, David!)
antirealist: “But if an RCT shows that only 5% of patients with X respond to wonderdrug, and you have X, what does that tell your physician about the probability you will respond to wonderdrug? EBM practitioners often seem to be operating with realist background assumptions – that there is a correct answer to the question, and RCTs can provide it.”
It tells your physician that, if you match the population studied in the RCT, you have a 5% chance of responding.
This is considerably better than a non-EBM approach where there is ABSOLUTELY NO WAY of making any such predictions.
“To give an example, there is a tendency in the EBM world to treat RCTs as if they represented a kind of epistemological gold standard (even though they may say they don’t, they do, which is why I say examine their methodology carefully). “
That would be because RCTs ARE the gold standard for testing hypotheses about medical treatments.
The situations in which they can be applied, however, are very, very limited.
The evidence in favour of EBM is so widespread and pervasive that I have trouble seeing how anyone can rationally challenge it.
“There are indeed powerful political and institutional interests backing EBM.”
So what?
This is simply an “ad hominem” attack and of no value whatsoever.
“Critics of EBM typically dispute EBM’s notion of what constitutes evidence, not the need for evidence in medical decision-making.”
Provide an example to support this statement.
“Clinical medicine is not a science. It is a practical discipline which deals with individuals. It utilizes techniques developed by, and discoveries made by science, but it is not itself a science.”
So what?
The same could be said for engineering or (practical) psychology (as opposed to research psychology).
When I go to see a doctor I am certainly an individual and I expect the doctor to take my individual characteristics (eg allergies) into account when diagnosing and treating my condition. I FAIL to see why this creates any problems for EMB.
antirealist, you make considerable reference to criticisms which could be made, but don’t actually make any!
I do want to know more. I googled, trying to find some of these criticisms, but didn’t find anything – probably because I didn’t know what to look for.
Links! I want links!
OB
Google “EBM criticism” and see:
Not a fan of wiki, but…
http://en.wikipedia.org/wiki/Evidence-based_medicine
and…
http://www.biomedcentral.com/1472-6963/3/14
and…
http://www.cebm.net/ebm_is_isnt.asp
The real debate (I think) hinges on how consider EBM, and its alternatives, are defined.
My GP (and her practice) do EBM but the notion that this ignores individual characteristics is laughable.
“Evidence-based medicine (EBM) applies the scientific method to medical practice.”
http://en.wikipedia.org/wiki/Evidence_based_medicine
Of course as a lay-person I had sorta assumed that medicine was already science-based, at least in the sense that, for example. the medicine my doctor prescribes has been tested to determine if it really will help get rid of X condition. So I am obviously not getting the nuances or even the basics of EBM.
But I found Holmes’ _political_ criticism so strange that it has piqued my interest in the subject.
•••
As to your desire for more links, OB, I would like to point out that while we are not Palm Springs, we do have some very nice ones in and around Seattle. Maybe B&W could sponsor a tournament next year?
antirealist wrote:
“Maybe you appear to have a lot in common, but you actually have (unknown to anyone, including your physician) a biologically-determined predisposition to respond favourably to the drug. Maybe you don’t, but you’re 35 years old with 3 kids and wonderdrug is your last hope. How does the RCT help you, your physician, and the people paying for your treatment decide what is best in your case?”
It depends on that “unknown to”. All we can ever do in any particular case is apply everything we know. So if it is a yet to be discovered fact that some people can have a biologically -determined predisposition to respond favourably to the drug, all we are left to work with are probabilities. And we know how to play them.
Think about it this way: suppose a process can have two results, one of which occurs 70% of the time (call it A), the other 30% (call it B). Suppose there is nothing known or knowable that allows you to distinguish, before an individual run of the process, between initial circumstances that are more likely to lead to one or other result than the 70/30 that is known anyway. What strategy of guessing the result will give the best rate of success in the long run? Answer: 100% of the time plump A. You will be correct 70% of the time and in the long run you cannot beat that.
Sometimes people think “the probabilities do not apply to me”. Unfortunately they always do.
Robyn Dawes wrote a great book on this subject, as it relates to psychology, “House of Cards” (http://www.amazon.co.uk/gp/product/0684830914/202-3874616-2459807). He is particularly scathing on psychologists who claim that their clinical experience can override the sort of probabilistic reasoning I outlined above – because psychologists have shown that clinical outcomes do not improve with clinical experience.
As Damon Runyan wrote, “The race is not always to the swift, nor the battle to the strong, but that’s the way to bet.”
Of course I don’t detect any fascism (mini- or macro-) either. In fact, the subject strikes me as kinda dull. But I definitely recommend the stuff about W.V. Quine’s “web of belief.” Now, that was really interesting.
http://www.biomedcentral.com/1472-6963/3/14
There’s a heading toward the middle of the article.
I’m confused, here. I’m confused for instance about “realist background assumptions.”
“EBM practitioners often seem to be operating with realist background assumptions – that there is a correct answer to the question, and RCTs can provide it. This is (or ought to be) Holmes’ point. Maybe you don’t have much in common with the population studied in the RCT. Maybe you appear to have a lot in common, but you actually have (unknown to anyone, including your physician) a biologically-determined predisposition to respond favourably to the drug.”
Aren’t there realist background assumptions in those last two hypotheticals too? Isn’t “you don’t have much in common with the population” a “correct answer to the question” “do you have much in common with the population?” Isn’t “you appear to have a lot in common, but you actually have (unknown to anyone, including your physician) a biologically-determined predisposition to respond favourably to the drug” a correct answer to the question “do you appear to have a lot in common, while you actually have (unknown to anyone, including your physician) a biologically-determined predisposition to respond favourably to the drug?”
Antirealist, aren’t you just saying sometimes answers are more complex than researchers (at first) realize, rather than that there are no correct answers? Or aren’t you. Note: I think there’s a correct answer to that question, but I don’t know what it is.
A central problem appears to be the idea that EBM relies solely on RCT (randomised controlled trials). It doesn’t and, due to the practical difficulty of doing RCTs, it is unlikely ever to do so.
RCTs are best for testing the efficacy of possible large-scale interventions (eg HRT or use of blood pressure medications such as statins).
They are impractical or impossible in other circumstances. That, however, doesn’t mean that EBM can’t be done.
This discussion, on the other hand, I think is a good one. Funny how these things vary!
Another thing I’m not clear about: does EBM refer to clinical practice, or to medical research? I was assuming it referred to research, but antirealist seems to be saying it refers to practice. Is that accurate, or just fancy footwork? Antirealist, are you being tricky there?
I retired from nursing (psychiatric) not long ago. The ever-changing stream of student nurses who were attached to the various settings in which I worked had all this kind of thing on their reading lists. The result was this:
http://www.telegraph.co.uk/health/main.jhtml?xml=/health/2006/08/07/nhospital05.xml
OB: “Another thing I’m not clear about: does EBM refer to clinical practice, or to medical research? I was assuming it referred to research, but antirealist seems to be saying it refers to practice.”
I think it’s both and I think antirealist was referring to practice.
For instance, an EBM approach to dealing with anxiety in a clinical setting (ie a patient presenting with anxiety) is to rely on approaches which have been tested and shown to be effective. Psychoanalysis, for instance, does not qualify whereas cognitive-behavioural therapy (CBT) does.
[OB: “This discussion, on the other hand, I think is a good one. Funny how these things vary!” Different strokes for different folks! 8-)]
Keith – I wouldn’t necessarily say that RCTs are always the best approach for large-scale interventions. Usually (although this is in part due to cost) they are used for smaller scale studies (typically 1500 subjects will be studied prior to a medicine being granted a license). Epidimiological studies are often more useful, particularly when it comes to determining safety, if only because they better reflect the actual patient population and patterns of clinical use.
oops, reading your comment again, I see that you specified efficacy, for which they are generally better than epidemiological studies.
sorry, I should learn to read