Deconstructing the evidence-based discourse in health sciences: truth, power and fascism – Int Journal of Evidence-Based Healthcare – 2006
This is an interesting critique of the ever-increasing focus on evidence-based medicine (EBM) in healthcare.
I agree that, while this seems purely scientific, the narrow focus on EBN actually undermines the human factor, which may lead to many more creative and compassionate approaches to practicing medicine.
EBM ignores all individual variation and, with what we know of genetics and biochemistry by now, this is a very UN-scientific approach. It also ignores the values and beliefs held by patients that are most critical to “healing”.
Drawing on the work of the late French philosophers Deleuze andGuattari, 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 micro-fascism at play in the contemporary scientific arena
The Cochrane Group, among others, has created a hierarchy that has been endorsed by many academic institutions, and that serves to (re)produce the exclusion of certain forms of research. 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.
Within the healthcare disciplines, a powerful evidence-based discourse has produced a plethora of correlates, such as specialized journals and best practice guidelines. Obediently following this trend, many health sciences scholars have leaped onto the bandwagon, mimicking their medical colleagues by saturating health sciences discourses with concepts informed by this evidence-based movement.2Inthe words of Michel Foucault, these discourses represent awesome, but oftentimes cryptic, political power that‘work[s] to incite, reinforce, control, monitor, optimize, and organize the forces under it’ (p. 136). Unmasking the hidden politics of evidence-based discourse is paramount, and it is this task that forms the basis of our critique.
Evidence-based health sciences: definition and deconstruction
Evidence-based practice derives from the work of Archie Cochrane, who argued for randomized controlled trials (RCTs being the highest level of evidence) as a means of ensuring healthcare cost containment, among other reasons
One the requirements of the Cochrane database is that acceptable research must be based on the RCT design; all other research, which constitutes 98% of the literature, is deemed scientifically imperfect
EBHS advocates defend its rigid approach by rationalizing that the process is not self-serving because improved health care and increased healthcare funding will improve patient outcomes.
Consequently, EBHS comes to be widely considered as thetruth.9When only one method of knowledge production is promoted and validated, the implication is that health sciences are gradually reduced to EBHS. Indeed, the legitimacy of health sciences knowledge that is not based on specific research designs comes to be questioned, if not dismissed altogether. In the starkest terms, we are currently witnessing the health sciences engaged in a strange process of eliminating some ways of knowing.
The health sciences take their lead from institutional medicine, whose authority is rarely challenged or tested probably because it alone controls the terms by which any challenge or test would proceed. Once it was adopted by medicine, the health sciences accepted RCTsas the gold standard of evidence-based knowledge. It is deeply questionable whether EBHS, as a reflection of stratification and segmentation, promotes the multiple ways of knowing deemed important within most health disciplines
We believe that health science sought to promote pluralism – the acceptance of multiple points of view.2However, EBHS does not allow pluralism unless that pluralism is engineered by the Cochranehierarchy itself.7Such a hegemony makes inevitable the further ‘segmentation’ of knowledge (i.e. disallowing multiple epistemologies), and further marginalize many forms of knowing/knowledge.
Thus, implicit in deconstruction is a suspicion of the essentialist and hierarchical nature of institutional knowledge. Ina deconstructive vein, we must ask not only, ‘What constitutes evidence?’ but also, what is the ‘regime of truth’ (Kuhn would call this a ‘paradigm’ and Foucault a ‘épistèmé’) that dictates when or how one piece of evidence shall count as evidence, while another is denigrated or excluded altogether? In other words, what makes one piece of evidence ‘self-evidently’ meaningful for us at this precise historical moment, while another appears so ‘self-evidently’ meaningless or nonsensical?
But we might ask: what is the fate of that evidence that is invisible to us – invisible, and yet still marginally felt and attested to?
It is becoming increasingly evident that an unvarying, uniform language – an ossifying discourse – is being mandated in a number of faculties of health sciences where the dominant paradigm of EBHS has achieved hegemony.14Thismakes it difficult for scholars to express new and different ideas in an intellectual circle where normalization and standardization are privileged in the development of knowledge.The critical individual must then resort to resistance strategies in front of such hegemonic discourses within which there is little freedom for expressing unconventional thoughts
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.
An evidence-based, empirical worldview 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.
Fascism and the fall of thought
The ossifying discourse that supports EBM is the result of an ideology that has been promoted to the rank of an immu-table truth and is considered, in learned circles, as essentialto real science. We could add here that its ossified language is a method of communicating in coded form, in stereotyped and dogmatic phraseology – an ideological message that will not be contradicted or challenged by its authors,b ut will always be understood by initiates. In this way, in its capacity as an ossifying discourse, the term ‘evidence-based movement’ (including concepts associated with it)sustains itself with its lexicon of acceptable ideas and forms
In his famous novel 1984, George Orwell coined the term “Newspeak” to describe a revised language purged from an affective tone.
Newspeak may be efficient, but in the ‘destruction of words,’it also operates to radically restrict the ways in which humans are mediated with their world and with others.
The mastery of scientific Newspeak is, for the most part, a regurgitation of prefabricated formulas (buzz words or catch words) that is informed by a single, powerful lexicon.This new guidebook of scientific vocabulary, including terms connected with EBM (e.g. systematic literature review, knowledge transfer, best practices, champions, etc.), is taken seriously in the realm of health sciences, so much so that it is considered vital as a reflection of ‘real science’. The classification of scientific evidence as proposed by the CochraneGroup thus constitutes not only a powerful mechanism of exclusion for some types of knowledge, it also acts as an organizing structure for knowledge and a mechanism of ideological reinforcement for the dominant scientific paradigm. In that sense, it obeys a fascist logic
The evidence-based enterprise invented by the CochraneGroup has captivated our thinking for too long, creating for itself an enchanting image that reaches out to researchers and scholars. However, in the name of efficiency, effectiveness, and convenience, it simplistically supplants all heterogeneous thinking with a singular and totalising ideology.
Authors: Dave Holmes RN PhD, Stuart J Murray PhD, Amélie Perron RN PhD(cand) and Geneviève Rail PhD, Faculty of Health Sciences, School of Nursing, University of Ottawa, Ottawa