I just came across a peer-reviewed paper from back in 2006 called ‘Deconstructing the evidence-based discourse in health sciences: truth, power and fascism‘, which appears to be enjoying another turn in the spotlight through the mind-melding magic of social media. It’s more or less a postmodernist rant against evidence-based medicine, filled with the usual jargon and incomprehensibility we’ve all come to know and love from postmodern academic literature. Apparently I’m not the only one initially thought it was another hoax paper – a number of tweets and blog posts have questioned the paper’s authenticity. As one Twitter user astutely points out, “You know your culture is screwed when it’s impossible to tell if something is a parody or meant seriously.”
But alas, it’s real. And it’s a tour de force! In it, the authors argue (if I’m decoding their opaque verbosity correctly) that the ‘regime of truth’ created by valuing one form of evidence over another in order to determine health-based strategies creates a hierarchy that excludes other ways of knowing which is best. They claim that ‘evidence-based medicine’ currently enjoys a ‘privileged status’ that needs to be deconstructed and blah, blah, blah. Honestly, I have trouble trying to figure out exactly what they’re saying. This was, no doubt, done on purpose.
To help decode this, I look to Ben Goldacre, MD:
… the argument of this paper – bear in mind 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 they enjoy (28 times).
First of all, a quick look at this evidence-based medicine they’re speaking of. From Wikipedia:
Evidence-based medicine (EBM) is an approach to medical practice intended to optimize decision-making by emphasizing the use of evidence from well-designed and well-conducted research. Although all medicine based on science has some degree of empirical support, EBM goes further, classifying evidence by its epistemologic strength and requiring that only the strongest types (coming from meta-analyses, systematic reviews, and randomized controlled trials) can yield strong recommendations; weaker types (such as from case-control studies) can yield only weak recommendations.
Sounds rather straight forward. If you’re going to be performing medical interventions, it’s probably a good idea to gather what you consider to be the best evidence for the procedure before proceeding, and having a system in place to rank sources of evidence. What is considered ‘the best evidence’ may be debatable, but it can probably be agreed (at least, it used to be) that certain types of studies are better than others and that all studies provide better evidence than, say, what your untrained neighbor thinks. But this paper seems to suggest otherwise. Here’s part of the abstract:
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.
A good example of a microfascism? Apparently that’s a thing. I wonder how many microfascists make up one fascist. And how many fascists are in a macrofascist? Are they measured in millihitlers?
Further on in the paper, they talk a little more about this microfascism:
The term fascism represents an emotionally charged concept in both the political and religious arenas; it is the ugliest expression of life in the 20th century. Although it is associated with specific political systems, this fascism of the masses, as was practised by Hitler and Mussolini, has today been replaced by a system of microfascisms – polymorphous intolerances that are revealed in more subtle ways. Consequently, although the majority of the current manifestations of fascism are less brutal, they are nevertheless more pernicious.
OK, let’s go with that. They’ve made up a new word to basically accuse evidence-based medicine of being a tyrannical system that rejects every type of evidence in favor of what they think is the best evidence. It’s basically like Hitler, only instead of rounding up people for slaughter based on their ethnicity, religion, political beliefs, or sexual orientation, they’re targeting medical practice that relies on evidence. Didn’t they think at some point that that’s a little hyperbolic? Apparently not:
In light of our argument, 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. The process at play here is one that operates hand-in-hand with powerful political or ‘power’ structures and that gears and sustains scientific assertions in the same direction: that of the dominant ideology. Unfortunately, the nature of this scientific fascism makes it attractive to all of us – the subjected.
I can see what they’re getting at here. Because evidence-based medicine values certain types of evidence over others, it may be too narrow a view and discount other possible ‘ways of knowing’. But it seems like a stretch to insist that, simply because consideration takes place in science about whether to value, say, randomized controlled trials over observational studies, that this means going with the latter makes you a fascist who ‘compels the subjected’ to share your worldview. If they stated their case more clearly, without all the postmodern word salad, and actually dialed back on the “let’s compare everything we don’t like to Hitler”, this might actually be a paper worth reading.
The fact is, however, that the EBM field has many varying opinions and is not some monolithic force with a single consensus viewpoint. As Richard Smith, former editor of The BMJ (British Medical Journal) says of the article:
But perhaps the biggest fault with their article is that the authors attack not the real evidence based medicine but a chimera they have created. It’s true that systematic reviews concentrate on well done randomised trials to assess the effectiveness of interventions, but Dave Sackett, “the father of evidence based medicine,” always argued that there are many other questions in health apart from “does it work?” and that those other questions need other methods to answer them. The Cochrane Library includes other studies apart from randomised trials and constantly explores new methods. Plus proponents of evidence based medicine have since the very beginning recognised that evidence alone cannot make decisions and that values are just as important.
I think what’s really at stake here is a fundamental difference in worldview between the scientist and the postmodernist. Here’s another quote from the paper:
We believe that EBM, which saturates health sciences discourses, constitutes an ossified language that maps the landscape of the professional disciplines as a whole. Accordingly, we believe that a postmodernist critique of this prevailing mode of thinking is indispensable. 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.
So there you have it. The authors have basically thrown out any semblance of a reasonable argument. Evidence-based medicine is bad because it relies on the assumption that objective reality exists. The postmodern assertion that the subjective experience of the individual is all that counts is completely at odds with the scientific view that objective reality not only exists, but is discoverable. Postmodernism is a mode of thought that denies a stable reality or the existence of reliable knowledge. No credence is given to an objective reality, or at most, it is put on equal footing with the subjective. Because postmodernism is, at its heart, an attack on truth, while science is a search for truth, the two are essentially antithetical. As Heather Heying puts it:
Postmodernism… [has] abandoned rigor and replaced it with ‘lived experience’ as the primary source of knowledge. Little credence is given to the idea of objective reality. Science has long understood that observation can never be perfectly objective, but it also provides the ultimate tool kit with which to distinguish signal from noise – and from bias. Scientists generate complete lists of alternative hypotheses, with testable predictions, and we try to falsify our own cherished ideas.
Science is imperfect: It is slow and methodical, and it makes errors. But it does work. We have microchips, airplanes and streetlights to show for it.
It’s little wonder then that a postmodern deconstruction would hold the idea of ‘best evidence’ in such low regard. Measuring objective reality is seen as ‘microfascism’ because it devalues ‘lived experience’. As Helen Pluckrose writes:
Above all, postmodernists attacked science and its goal of attaining objective knowledge about a reality which exists independently of human perceptions, which they saw as merely another form of constructed ideology dominated by bourgeois, Western assumptions.
The authors do walk it back a bit in the next paragraph, stating “Of course, we do not wish to deny the material and objective existence of the world…” but they go on to say that, because our experience of the world is always mediated through a subjective lens, the objective doesn’t matter. This essentially boils down to the same thing: “Your ‘evidence’ isn’t any better than how I feel about the subject, goddammit!”
This emphasis on subjective feelings is evident where the authors state that, “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…”
It’s all about ‘the feels’. In fact, it’s ‘dangerous’ to not give serious weight to the feels. But what exactly is the danger here? That someone might get their feelings hurt? That going with the best available evidence might offend someone whose opinion wasn’t considered? Or does the real danger lie in discounting something with strong evidence of efficacy because it was discovered by a white cis-male who didn’t take into account ‘minority viewpoints’.
To be blunt, this perspective is essentially insane. The assertion that objective reality is ‘just one subjective experience’, and that all perspectives and opinions therefore constitute valid, actual evidence, the studiously collected data via the scientific method becomes just another opinion in an infinite soup of perspectives. It’s a rejection of any type of valuation, any type of measured assessment of one form of evidence over another. This worldview completely counters what is vitally necessary for a functioning society, at all levels. I’m trying to come up with an example here, but it’s hard to think of a single facet of human existence where the belief in, and value of, a stable objective reality outside our subjective experience of that reality isn’t completely necessary in order to function.
EBM is certainly not above criticism, mind you. One problem is that the evidence base is skewed by financial interests, meaning the only things getting researched with placebo-controlled trials are things that have big earning potential – i.e., pharmaceutical drugs. It would be different if the better part of studies were being performed by companies without direct financial incentive, but since the vast majority of expensive studies have the goal of monetizing the results in some way, the ‘evidence’ ends up incredibly one-sided. And because the evidence is all based on pharmaceuticals, the illusion is created that pharmaceuticals are the only option. For instance, in some cases behavioral interventions may actually be more beneficial than pharmaceutical interventions, but the incentive for performing studies of this sort would necessarily have to be other than financial. The totality of the evidence, therefore, is weighted heavily in favor of where the funding directs it.
And, for this reason, there’s also the issue of corruption. It appears pretty easy for capitalistic forces to warp the EBM field in the direction of money-making ventures at the cost of the truth. The shady practices of pharmaceutical, agrichemical and food processing companies – in skewing data, manipulating studies, or simply not publishing undesirable findings – is well documented. These actions are ripe for criticism in the field. It’s not that evidence is exclusionary in and of itself; it’s that the evidence is being tampered with.
But by sticking with their postmodern lens, seeing everything as being about power and chastising scientists for daring to try to measure an objective reality that apparently doesn’t exist, the authors miss out on what could be a valid criticism of EBM. It’s true that there are multiple ways of collecting evidence and that randomized controlled trials may not be the best tool for the job in some cases. What should be counted as evidence, and how that evidence should be weighed, is an ongoing debate in many scientific fields. But the spurious notion that all evidence is equal because all lived experience is equal and valid threatens the very basis of science itself. This is a very, very bad thing.
A true test of how committed the authors are to this insane perspective would be to take a look into their personal lives to see if they’re walking the talk. If, theoretically, one of them, or one of their loved ones, required a medical intervention for a serious condition, would they go with an evidence-based solution (keeping in mind that this might reject the stock treatment that actually lacks evidence, which is the case more often than one might think, and may include alternative treatments with some semblance of evidence behind them), or would they go with something based on ‘another way of knowing’ – folklore, intuition or faith-healing, for example? Some sort of hypocrite test should become a standard operating procedure for assessing postmodern claims.
To end with, here’s a video of some ‘Fallist’ (whatever the hell that is) saying that science must be “decolonised”, “done away with entirely,” and “started over again,” for the reason of making it more inclusive of differing perspectives, and also seems to be advocating for the inclusion of black magic and witchcraft. Flat-Earthers have nothing on these guys.
Doug DiPasquale is a Holistic Nutritionist, Paleo enthusiast and health journalist living in Toronto, Canada. He’s a regular contributor for SOTT.net, Dot Connector Magazine, the Huffington Post Canada, The Food Network Canada and has contributed to many other blogs and online publications. He’s passionate about the food we eat, exposing the lies and faulty thinking of the “food police” and informing the public about how to eat real food, ie. replacing that wheatgrass shot with bacon.