Sometimes you know an academic paper has overplayed its hand just from the title. ‘Deconstructing the Evidence-Based Discourse in Health Sciences: Truth, Power and Fascism’– from the current International Journal of Evidence-Based Healthcare – is one such paper. Even Rik Mayall in The Young Ones might pull back from using the word ‘fascist’ – or derivatives of it – twenty-eight times in six pages.
Initially I thought it might be a spoof. After all, who could forget the Sokal hoax, where a Professor of Physics at NYU submitted ‘Transgressing the Boundaries: Towards a Transformative Hermeneutics of Quantum Physics’ to Social Text, the leading postmodernist academic journal. This deliberately meaningless joke article – purporting to undermine the entire discipline of physics – was accepted and published, to universal delight.
But this new article is very real. Here’s what the authors 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.’
If I can put my fascist cards on the table, these are not ‘objectives’. Setting details aside, here is a quote from their authority figure, French philosopher Félix Guattari, to illustrate the clarity of his thinking: ‘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.’ And from Gilles Deleuze: ‘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 – it’s not an easy read – seems to be that: evidence-based medicine rejects anything that isn’t 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 the authors enjoy, twenty-eight 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 make repeated allusions to Newspeak. At one point they seem to identify epidemiologists with George W. Bush.
Now, firstly, they are plain wrong about the Cochrane Library, an organisation which simply produces systematic reviews of the published medical literature: Cochrane doesn’t only use trial data, in fact many Cochrane reviews contain no trials at all. This is pure ignorance.
But there is a more important general issue here. Evidence-based medicine is often portrayed – especially by ageing professors from the dying era of eminence-based medicine – as soulless and algorithmic. But that is a foolish caricature. EBM, in all the key textbooks, from the earliest editorials, is about using quantitative information alongside all other forms of knowledge: taking account of clinical judgement, and patients’ wishes, and boring things like the availability of local services. It does not denigrate other forms of knowledge, like clinical experience or patient preference: it seeks to augment and inform them. EBM is not about being an automaton.
That’s all a bit sensible. How about some more childish attacks, ideally involving fascism? OK, then. I will wear their label of ‘fascist’ with a cheeky grin. But Archie Cochrane, on the other hand – pioneering epidemiologist, and inspiration for the Cochrane Library – might see things a little differently. After the war, and after working on miners’ lung disease, he helped to inspire a democratising culture shift towards evidence-based practice throughout the whole of medicine, and as a consequence, he has probably saved more lives than any single doctor you know. Before that, he was a prisoner of war for four years in Nazi Germany (‘The main reason for my capture was my inability to swim to Egypt’). And before that, 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.
Archie Cochrane (left) as a captain in the International Brigade, c.1936.
Now. What did you do in your summer holidays?