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.

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

A Former Editor Cites Foucault

A while back, we posted about the firing of the editors of the Canadian Medical Association Journal (CMAJ), noting this seemingly unfortunate example of a power struggle within a medical organization. However, the firing of Dr Hoey has generally been presented in terms of abuse of power as a violation of editorial independence.

For example, in 2005, Hoey wrote an unsigned editorial in CMAJ that started with the premise, "freedom from interference in editorial decisions stands at the heart of the credibility of any reputable journal." He then announced "we have a transgression to report," and then went on to recount how "a CMA [Canadian Medical Association] executive objected strenuously to a news article we were preparing on behind-the-counter access to levonorgestrel (Plan B)."(1) Similarly, the editor of the British Medical Journal responded to Hoey's firing, "this is a sorry tale that shows how little the CMA (its officers and - since there is no sign of a concerted outcry from them - its members) understands what it means to be the custodian of an international academic medical journal."(2)

There has been much more discussion of the firing of Hoey and then the departure of many other CMAJ editors. The New England Journal of Medicine ran a commentary in March.(3) Last week, it ran another, this time written by Dr Hoey, himself.(4) Would this more clearly delineate what happened?

Hoey's article, however, took an unusual stance. He chided "owners [who] may wish to limit to limit the scope of their journal, to restrict its editorial perspective to matters of bedside medicine and the narrower interests (as perceived by the usually nonphysician publishers) of their physician readership." He then denied this "vision." Instead, he proclaimed, "for Foucault, medicine is a political act."

That is where he lost me, decisively. The Foucault he cited, assuredly is Michel Foucault, one of the "postmodern vanguard," authorities repeatedly cited to justify the fashionable post-modern concepts that have swept through the academic humanities and social sciences. Foucault is cited:

• For his hostility to the Enlightenment. For example, he wrote, "it is meaningless to speak in the name of -or against - Reason, Truth, or Knowledge."(5) Hicks explained, "Postmodernism rejects the entire Enlightenment project. It holds that the modernist premises of the Enlightenment were untenable from the beginning and that their cultural manifestations have now reached their nadir. While the modern world continues to speak of reason, freedom, and progress, its pathologies tell another story. The postmodern critique of these pathologies is offered as the death knell of modernism: 'The deepest strata of Western culture' have been exposed, Foucault argues, and are 'once more stirring under our feet.'"(6)
• To support the self-contradictory and ultimately meaningless assertion that there is no external reality, that reality is "socially constructed." "Foucault at times suggested that underlying what counts as objective knowledge is a power relation, one category of people benefiting at the expense of another category of people. The radicals thus see the social construction of reality...."(7)
• To support totalitarianism. "As part of the attack on the Enlightenment, the critique of truth suffers from a tendency to reinforce pre-enlightenment despotism. The Enlightenment replaced individual and institutional power with more objective measures of validity, and it is no surprise that the rejection of objectivity collapses back into power as a means for defining absolute truth."(8) Foucault's belief that "liberal democracies are actually more oppressive than medieval despots or even modern totalitarians,"(9) was consistent with his occasional embrace of totalitarian rulers. In 1971, he said, "when the proletariat takes power, it may be quite possible that the proletariat will exert toward the classes over which it has triumphed a violent, dictatorial, and even bloody power. I can't see what objection could possibly be made to this."(10) Similarly, he extolled the 1978 Iranian revolution, "exulting in the 'intoxication' of revolution and the violent expression of 'collective will,' and praised its leaders 'political spirituality,' which he thought reflected a health 'religion of combat and sacrifice.'"(11)

In my humble opinion, citing Foucault as an authority suggests a sympathy for post-modernism that would not be helpful to a journal editor. Most of editing is about science, and science does not fit with the notion that external reality does not exist. Readers of Health Care Renewal are certainly aware that medicine and health care are influenced by politics. But the notion that politics is all of medicine, or a totalitarian world view will not help us address concentration and abuse of power.
But perhaps Hoey's citation of Foucault was a mistake, or misinterpretation. After citing Foucault, Hoey admonished journal editors not to discuss or even divulge editorial decisions to their publishers, for that would "gut the editorial independence of a journal." However, the editor's outlook and assurance should include "an eager propensity to poke a stick into something or somebody." That proclamation suggests that Hoey's reliance on Foucault was not some mistake. Characterizing an ideal journal editor as an undisciplined trouble-maker fits Foucault's fascination with "limit experiences."(12) Yet editors whose main joy is in poking sticks into something or somebody without restraint or accountability will only add to concentration and abuse of power.
Thus, it still seems like our original characterization of the dispute at CMAJ was apt, "A classic power struggle within medicine's increasingly less-hallowed halls. Here it seems drearily familiar." That's too bad.
References
1. CMAJ. The editorial autonomy of CMAJ. Can Med Assoc J 2006; 174: 9.
2. Godlee F. A big mistake. Brit Med J 2006; 332:
3. Shuchman M, Redelmeier DA. Politics and independence - the collapse of the Canadian Medical Association Journal. N Engl J Med 2006; 354:1337-1339.
4. Hoey J. Editorial independence and the Canadian Medical Association Journal. N Engl J Med 2006; 354: 1982-3.
5. Hicks SR. Explaining Postmodernism: Skepticism and Socialism from Rousseau to Foucault. Tempe: Scholargy Publishing, 2004. P. 2. (Link here)
6. Hicks, P. 14.
7. Farber DA, Sherry S. Beyond All Reason: the Radical Assault on Truth in American Law. New York: Oxford University Press, 1977. P. 24. (Link here)
8. Farber, Sherry. P. 106.
9. Farber, Sherry, P. 29
10. Lilla M. The Reckless Mind: Intellectuals in Politics. New York: New York Review of Books, 2001. P. 150. (Link here.)
11. Lilla. P. 154.
12. Lilla. P. 150.

Post Title → A Former Editor Cites Foucault

Teaching Anti-Science: "Intelligent Design" and Postmodernism

As noted in an earlier post, the New England Journal of Medicine last week featured a commentary by Robert S Schwartz that worried that the "anti-science movement" of "intelligent design" would soon infect medical schools. [Schwartz RS. Faith healers and physicians - teaching pseudoscience by mandate. N Engl J Med 2005; 353: 1437-1439.]
Schwartz wrote:

the movement to teach intelligent design has spread from school houses to college campuses and university postgraduate programs. I fear that it will soon reach medical schools.
Some might ask why physicians should care about how we educate our children, and what difference it would make if we taught children intelligent design as a counterweight to evolution.... But acquiescing to this anti-science movement would have far-reaching consequences for the development of future generations of physicians, for the likelihood of discovering new therapies, and for understanding health and disease.

I agree with Schwartz that we should worry about students being taught anti-science in K-12 education, college, and graduate school. But if we should worry about the prospects of students being taught "intelligent design," maybe we should worry even more about them being taught post-modernism. After all, intelligent design has not been introduced into many curricula, yet postmodernism now dominates the humanities, and sometimes the social sciences at our most prominent universities.
Epstein provided a useful summary of postmodernism, shorthand for "the amalgam of postmodernism, poststructuralist theory, deconstruction, and political moralism, ... [which] has come to hold sway in large areas of academia." Postmodernism "has its origins in the writing of a group of French intellectuals of the 60s, most preeminently Michel Foucault, Jacques Derrida, Jacques Lacan, and Jean-Francois Lyotard." "Postmodernism rejected aspects of the structuralism legacy, particularly its emphasis on the stability of social structures but retained its focus on language, the view that language provides the categories that shape self, society. This could be extended to the view that all reality is shaped by language; it could suggest that language is real, everything else, constructed or derived from it." "In the latter part of the 70s, many young people whose center of attention was shifting from the movements of the 60s to intellectual work, often in the academy, were avidly reading Foucault. Many were also reading other French intellectuals, including French feminists such as Luce Irigaray, Monique Wittig, the eclectic theorists of society and psychology, Gilles DeLeuze and Felix Guattari, the Marxist structuralist, Louis Althusser, the psychoanalytic structuralis, Jacques Lacan. Through the works of these writers and the debates in which their work was embedded, the poststructuralist ideas that had come to dominate French radical intellectual circles in the late 60s and 70s filtered into parallel intellectual circles in the U.S." So, "there are many academic departments and programs that associate themselves with progressive politics in which the subculture of postmodernism holds sway. This is especially the case in interdisciplinary programs, especially those in the humanities; postmodernism is most likely to be the dominant perspective if the institution is relatively prestigious and if the faculty has been hired since the 60s."[1]
In the central core of postmodernism are radical skepticism about the existence of external reality, and the notion that all truth is socially constructed. For example, postmodernism has been described as questioning "the fundamental philosophical and political premises of the West. It argues that many of the concepts we take for granted - including truth, morality, and objectivity - are culturally 'constructed.'"[2] Lyotard has suggested that postmodernism is a "disbelief in metarecits, or philosophical metanarratives, such as 'Science' and 'Truth'...." So, "everything is contingently good or bad or true or false."[3]
Postmodernist extreme relativism is antithetical to science. As Epstein stated, "because all perception of reality is mediated, because what we regard as reality is perceived through discourse, there is no truth, there are only truth claims. Since there is nothing against which these claims can be measured, they all have the same standing."[1]
Some postmodernists may be frankly hostile to science. Thus in the same issue of Social Text that contained Sokal's famous parody of post-modernist writing about science,[4] Levins wrote, "Modern European/ North American science is a product of the capitalist revolution." "Like bourgeois liberalism in general, it is both liberated and dehumanized. It proclaimed universal ideals that it did not quite mean, violated them in practice, and sometimes revealed those ideals to be oppressive even in theory."[5]
Other postmodernists have challenged fundamental aspects of science education. They have suggested "that students be explicitly disabused of any ideas they might have picked up about the epistemic desirability of reproducible experiments, controlling variables, statistical analysis, and all the other methodological staples of modern science."[6]
Postmodernists have more specifically challenged biomedical science, and its methodological basis. Levins wrote, "We can approach the dominant modalities of chemical therapy in medicine and farming as expressions of the commoditization of knowledge by the chemical industry."[5] Berkwits argued that "the preeminence of clinical epidemiologic research in medicine derives not from its ability to reveal the truth about clinical phenomena, but from an agreement within the medical community for a variety of reasons that it will grant greater authority to statistical expressions of evidence over others." So, the randomized clinical trial (RCT) has achieved its favored status is not that it more likely to produce results that approximate the truth than can other research designs, but because it "emerged from social circumstances to become its own standard of objectivity." So, "in this way, a method which initially served pragmatic social purposes became a self-authenticating criterion for objective clinical truths."[7] Similarly, Kaptchuk argued "In a self-authenticating manner, the double-blind RCT became the instrument to prove its own self-created value system."[8]
Finally, postmodernism undermines logical and rational thinking which is the foundation of science. As Gergen put it, "the texts of postmodernism find the concept of individual rationality deeply problematic, if not oppressive, in its function."[9] Then consider the argument by Social Text editor Bruce Robbins, "truth can be another source of oppression. It was not so long ago that scientists gave their full authority to explanations of why women and African-Americans (not to speak of gays and lesbians) were inherently inferior or pathological or both. Explanations like these continue to appear in newer and subtler forms. Hence there is a need for a social constructionist critique of knowledge."[10] Thus Robbins argued that because some people may say false things, there is no such thing as truth. As Sokal said, "this error is, unfortunately, repeated throughout Robbins' essay: he systematically confuses truth with claims of truth, fact with assertions of fact, and knowledge with pretensions to knowledge." [11] Bouveresse suggested that the tactics of postmodernists include: "start again by making a flamboyant assertion that is either illogical or unsupported by evidence: then, when challenged, pose as a victim and accuse your opponents of being 'flies de la pensee,' [thought cops], 'gendarmes,' and 'censeurs' [censors]." So that "when criticisms, even the most well-founded ones, are directed against intellectuals [postmodernists] of a certain stature, they are considered ipso facto prosecutorial and inquisitorial...."[12]
Anyone with doubts about the reach of postmodernism should look at the descriptions of humanities courses at nearly any highly ranked US college or university.
Schwartz suggested that "leaders of professional societies and prominent academicians should start speaking up" about the prospect that intelligent design may be taught in schools and colleges. In the 1990's, they should have spoken up about post-modernism. A few in the physical sciences and mathematics, such as Alan Sokal and Norman Levitt begin objecting to post-modernism then. It's time for leaders in the health sciences to catch up.

References
1. Epstein B. Postmodernism and the left. New Politics, 1997; 6.[link]
2. Rothstein E. Attacks on the U.S. challenge the perspectives of postmodern true believers. New York Times, September 22, 2001.
3. Sarchett BW. What's all this fuss about this postmodernist stuff? In Arthur J, Shapiro A, ed. Campus Wars: Multiculturalism and the Politics of Difference. Boulder, CO: Westview Press, 1995. Pp. 19-28.
4. Sokal A. Transgressing the boundaries: towards a transformative hermeneutics of quantum gravity. Social Text 1996; 46/47: 217-252. [link]
5. Levins R. Ten propositions on science and antiscience. Social Text 1996; 14: 101-110.
6. Koertge N. Postmodernisms and the problem of science literacy. In Koertge N, editor. A House Built on Sand: Exposing Postmodernist Myths About Science. New York: Oxford University Press, 1998. Pp. 257-271.
7. Berkwits M. From practice to research: the case for criticism in an age of evidence. Soc Sci Med 1998; 47: 1539-1545.
8. Kaptchuk TJ. Powerful placebo: the dark side of the randomised controlled trial. Lancet 1998; 351: 1722-1725.
9. Gergen KJ. Psychological science in a postmodern context. Am Psychologist 2001; 56: 803-813.
10. Robbins B. Anatomy of a hoax. Tikkun 1996; 11: 58-59.
11. Sokal A. A plea for reason, evidence, and logic. New Politics 1997; 6: 126-129. [link]
12. Bricmont J, Sokal A. Modesty, rigor and irony: some remarks on Prodiges et Vertiges de L'analogie: De L'abius des Belles Lettres dans la Pensee by Jacques Bouveresse. Agone 2000; 24: 115-122.[link]

Post Title → Teaching Anti-Science: "Intelligent Design" and Postmodernism