The Post-Modernist View: Evidence-Based Medicine as Fascism?

As many of you realize, I am an advocate of evidence-based medicine (EBM), roughly defined as medicine based on critical review of the best availalble evidence from clinical research, combined with clinical judgment, knowledge of biology, and patients' values and preferences. (See also: "Evidence-Based Medicine: What It Is and What It Isn't" from the 1996 British Medical Journal for a better explanation.)

Some of us who advocate EBM see it as an antidote to health care based on dogma, ideology, or commercial interest.

Unfortunately, although EBM has generated a lot of enthuisiasm among its advocates, it has been a hard sell in the larger health care world. I have always suspected one reason for this is that EBM potentially challenges ideas, programs, and products in which people believe, or in which people have vested interests. If you really believe gizmo X works, or if you make a lot of money selling gizmo X, you may not be enthused about a rigorous review of the evidence that suggests that maybe gizmo X doesn't work so well.

In any case, by 2002, only about one-third of US and Canadian internal medicine residencies included any time for EBM (Hatala R, Guyatt G. Evaluating the teaching of evidence-based medicine. JAMA 2002; 288: 1110-1111.) In 2004, "now most medical programmes in the United States attempt to teach EBM, although few succeed...." ( Del Mar C, Glasziou P, Mayer D. Teaching evidence based medicine: should be integrated into current clinical scenarios. Brit Med J 2004; 329: 989-990.)

Thus my jaw dropped when I saw an article entitled "Deconstructing the evidence-based discourse in health sciences: truth, power and fascism." (Full citation: Holmes D, Murray SJ, Perron A, Rail G. Deconstructing the evidence-based discourse in health sciences: truth, power and fascism. Int J Evid Based Healthc 2006; 4: 180-186.) This article has already created quite a bit of buzz among those who are skeptical about post-modernism, and those who advocate for EBM, i.e., people like me.

The paper is written in the usual turgid post-modernist style, with all the expected bowing and scraping to Foucault, Derrida, Lyotard, Deleuze, Guttari, etc, the tortured sentence structures, and the obscure ("interpellated"), and sometimes apparently made-up words ("hysterisation").

The paper includes some almost hilarious accusations. As noted above, providing effective teaching of EBM in medical schools and post-graduate medical education has been difficult. In medical schools that I have seen, EBM advocates are a minority, sometimes embattled. Yet Holmes et al accuse EBM of being so powerful that "in a number of faculties of health sciences ... the dominant paradigm of EBHS [evidence-based health science] has achieved hegemony." Moreover, according to Holmes et al,

Rather than risk being alienated from their colleagues, many scientists find themselves interpellated by hegemonic discourses and come to disregard all others. Unfortunately,privileging a single discourse (evidence-based medicine (EBM)) situated within a single scientific paradigm (postpositivism) confines the researcher to a yoke of exactly reproducing the established order. To a large degree, the dominant discourse represents the ladder of success in academic and research milieus where it establishes itself as a weapon used against those who praise the freedom of scientific inquiry and the free debate of ideas.

Say what? I'm sure all those who struggled to get a few hours of EBM instruction into about one-third of internal medicine residencies by 2002 will be gratified to know that they are supposed to be on "the ladder of success in academic and research mileius." The notion that someone thinks EBM has been used to suppress free speech is just plain mind-boggling, although post-modernism has certainly been used to justify the suppression of free speech. (See, for example, the title essay in There's No Such Thing as Free Speech, and It's a Good Thing, Too by Stanley Fish.)

If anyone knows of such an institution, please tell me about it so I can apply there for a job.

Holmes et al also asserted that EBM advocates get "institutional promotions and accolades, public recognition, and state contracts of all kinds." Huh? Boy, I sure have missed out, and so have many of my friends and colleagues. At least in the US, EBM has not exactly been high on the priority list for federal government funding. (To add further irony, the article by Holmes at al was funded by one of those "state contracts of all kinds." Their paper was funded by the Canadian government, through the Canadian Institutes of Health Research- Institute of Gender and Health.)

But the paper goes from hilarious to nasty (which is why I don't believe that it was a hoax or a parody). The paper literally accuses advocates of evidence based health of being fascists,

Drawing in part 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. The philosophical work of Deleuze and Guattari1 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.

Them's close to fightin' words.

Holmes and colleagues then specifically accuse the Cochrane Collaboration of being a fascist organization,

The classification of scientific evidence as proposed by the Cochrane Group thus constitutes not only a powerful mechanism of exclusion for some types of knowledge, it also acts as an organising structure for knowledge and a mechanism of ideological reinforcement for the dominant scientific paradigm. In that sense, it obeys a fascist logic.

Furthermore,

Fascism is not too strong a word because the exclusion of knowledge ensembles relies on a process that is saturated by ideology and intolerance regarding other ways of knowing.

To get more of tthe flavor of Holmes and colleagues arguments,

A starting point for health sciences would be to promote the multiplicity of what Foucault describes as subjugated forms of knowledge (savoirs assujettis): these forms of knowledge are ways of understanding the world that are ‘disqualified as non-conceptual knowledges, as insufficiently elaborated knowledges: naïve knowledges, hierarchically inferior knowledges, [and] knowledges that are below the required level of erudition or scientificity’ These forms of knowledge arise from below, as it were, in contradistinction to the top-down approach that characterises the hegemonic thrust of EBHS. For Foucault, a subjugated knowledge is not the same thing as ‘common sense’. Instead, it is ‘a particular knowledge, a knowledge that is
local, regional, or differential’

In our view, this positive process begins with a critique of EBHS and its hegemonic norms. As we have argued, according to postmodern authors, these norms institute a hidden political agenda through the very language and technologies deployed in the name of ‘truth’. Again, Foucault sums up this position in his critique of modern medicine: ‘Medicine, as a general technique of health even more than as a service to the sick or an art of cures, assumes an increasingly important place in the administrative system and the machinery of power’ Here, in such an ‘administrative system’ and a ‘machinery of power’, we find a classic allusion to what Hannah Arendt defines as totalitarianism or fascism, as we defined it earlier.

That should make Hannah Arendt, a true foe of totalitarianism, spin in her grave.

Finally, Holmes et al compared the language of EBM with "Newspeak" in 1984. I invite readers to read the article by Holmes et al, compare it to some article that is reasonably typical of those that advocate for EBM (such as the one from the 1996 BMJ linked above) and decide which is more like Newspeak.

The pity is that post-modernism's word-play mumbo jumbo and its cults of personality seem to be a great way for academic institutions to distract themselves from what is really going wrong with health care, the real threats to our professional values of the sort we have documented on Health Care Renewal.

Recovering from the brain fever induced by reading about "colonised (territorialised) science," "regimes of knowledge," "interpellated academics," and the "hysterisation of the female body," one might speculate: Has post-modernism been deliberately encouraged by some academic leaders, possibly those with the most severe conflicts of interest, to distract us from concentration and abuse of power in health care, the pervasiveness of conflicts of interests in health care organizations, and unethical and even illegal behavior by health care leaders?

If so, it's working.

ADDENDUM (25 August, 2006). See also the commentary in the Guardian (UK) by Ben Goldacre.