The revenge of “microfascism”: PoMo strikes medicine again

It’s grant crunch time, as the submission deadline for revised R01s is July 5. However, in a classic example of how electronic filing has actually made things more difficult, the grant has to be done and at the university grant office a week before the deadline if it is to be uploaded in time. So, my beloved Orac-philes, I’m afraid it’s reruns again today, but, benevolent blogger that I am, I’ll again post two about the same topic. Since I recently reran a really old post that started it all, I thought I’d follow up with the two additional posts about the same topic. This is the third one and is from 2008, which means that if you haven’t been reading at least three years it’s probably new to you!

I hate postmodernism.

Well, not exactly postmodernism per se, but I hate it when pseudoscientists and purveyors of dubious “alternative” medicine treatments invoke bizarre postmodernist-sounding arguments to attack science or, in the case of medicine, science- and evidence-based medicine. Usually these attacks involve a claim that science is nothing more than one other “narrative” among many others, a “narrative” that isn’t necessarily any more valid than any other. Even worse, these sorts of arguments often claim that science (or, in this case, evidence-based medicine) is nothing more than a sort of hegemony of the power structure being imposed upon the very definition of “data” or “reality,” the implication that it’s us white males whose hegemony rules (and, presumably, must be resisted) doing the imposing, as if there are no inherent characteristics in science that make it a more valid means of assessing reality as it exists than, for example, personal anecdote and “experience.”

A couple of years ago, I came across the epitome of silly postmodernist rants (a.k.a. “PoMo”) that, possibly until now, has exceeded anything I had ever seen applied to medicine before. Basically, it was an all-out assault on the paradigm known as evidence-based medicine (EBM), a paradigm that ranks types of evidence by their rigor, ranking as the highest form of evidence the well-designed, randomized, double-blinded clinical trial. In this all-out assault, the authors of the article in essence played the argumentum ad Nazium gambit and labeled EBM “microfascism” in a hilariously over-the-top screed entitled Deconstructing the evidence-based discourse in health sciences: Truth, power, and fascism. Later that year, after a barrage of withering criticism, the authors of the study, David Holmes, Stuart J. Murray, Amélie Perron, and Geneviève Rail launched an even more hiliarious response. I strongly encourage you to take a trip back to two years ago and read about it before proceeding. Why?

Because three of the original Four Horsemen of the PoMo-calypse ride once again, spreading verbiage, confusion, and, above all, headaches to anyone who tries to penetrate the denseness of their blather, and they’re even more unhappy than ever about EBM. One of the bloggers at Holford Watch let me know about it, and I’m not sure if I should thank him or or curse him for it. We’ll see. In the meantime, the abstract alone is some of the most concentrated PoMo gibberish I’ve ever seen:

Drawing on the philosophy of Michel Foucault and Gilles Deleuze, this paper interrogates the constitution of ‘evidence’ that defines the evidence-based movement in the health sciences. What are the current social and political conditions under which scientific knowledge appears to be ‘true’? Foucault describes these conditions as state ‘science’, a regime that privileges economic modes of governance and efficiency. Today, the Cochrane taxonomy and research database is increasingly endorsed by government and public health policy makers. Although this ‘evidence-based’ paradigm ostensibly promotes the noble ideal of ‘true knowledge’ free from political bias, in reality, this apparent neutrality is dangerous because it masks the methods by which power silently operates to inscribe rigid norms and to ensure political dominance. Through the practice of critique, this paper begins to expose and to politicise the workings of this power, ultimately suggesting that scholars are in a privileged position to oppose such regimes and foremost have the duty to politicise what hides behind the distortion and misrepresentation of ‘evidence’.

Wow. Just wow. This is almost as good (bad) as whole “microfascism” rant. Basically, it’s the same tired old refrain that science is nothing more than the existing power structure exerting its will to enforce “conformity.” Because the article is not available to a lot of my readers, I feel obligated to quote fairly liberally from it to give you a flavor of just how ridiculous it is. The authors’ intent is made plain right from the first sentence:

What constitutes ‘evidence’ in the health sciences? Without too much hesitation, we might say that scientific evidence is worthwhile if it can be repeated, independently verified and measured according to standards upon which we can all agree. We might call this the ‘common sense’ view and commonsensically believe that these conditions hold as true not just in the sciences but also in our daily dealings in the world. We might even say that nothing could be more straightforward, that evidence in this context is obvious or ‘self-evident’ and that in the end, ‘seeing is believing’. In this paper, we suggest that this cheerful proverb stands as a kind of emblem for the dangerously naïve commonsense view on truth that has spread throughout our culture. We argue that this view betrays an almost unshakeable faith in the human capacity for unbiased or objective observation and analysis. Ultimately, this means that science becomes supplanted by ideology, and scientific inquiry becomes a ‘methodological fundamentalism’ (House, 2006).

Yes, it’s the old “fundamentalism” charge leveled against those of us who actually think that scientific rigor is important in determining what treatments work and what treatments do not. It’s the same charge routinely leveled against evolutionary biologists by creationists, be they “intelligent design” creationists or the old hard core young Earth creationists. It’s the same charge leveled by pseudoscientists of all stripes against scientists who correctly tell them they are pseudoscientists: That scientists are rigid, unable to think “outside the box,” to them, as I mentioned before, science is nothing more than a Tool of the Man to enforce cultural hegemony and, more importantly, to keep the Brave Mavericks down. In fact, the entire premise of this article is based on a huge straw man, as is shown here:

This paper discusses the constitution and status of ‘evidence’ in light of the almost evangelical rise of evidence-based health sciences (EBHS), including nursing. One salient example is the Cochrane Library, which provides EBHS acolytes with a database of ‘systematic reviews’ that has been faithfully constructed according to the evidencebased movement (EBM) directives. Thus, within the Cochrane Library’s hierarchy of allowable ‘evidence’, the randomised controlled trial (RCT) is taken as the ‘gold standard’, and proponents will scoff at any criticism because the RCT can be repeated, independently verified and measured according to standards upon which we can all (presumably) agree. It is not rocket science, or so they will say. But here with the seemingly innocent exaltation of the RCT, we find an explicitly hierarchical ranking that denigrates the evidentiary value of clinical experience; and similarly, qualitative research based, among other things, on participants’ narratives is ‘systematically’ ranked lower in value as ‘evidence.’

Thus, the most faithful proponents of EBHS must adopt a position in which “seeing is believing”–where evidence is presumed to be visual, immediate and incontestable. It is as if the evidence itself spoke the truth, and EBHS finally realised the dream of a pure science, a science free from the inherent messiness of human language, of human interpretation, of human values or, indeed, of anything recognisably human because the body that EBHS treats is the ‘average body’ generated by the RCT, without any experimental body. Nevertheless, within the culture of the health sciences, EBHS now circulates as a kind of fundamental truth, and it can do so because EBHS has come to control the terms by which evidence appears. The EBM constitutes a vast matrix of influence from funding bodies and academic institutions to nursing best-practice guidelines (BPGs) and multiple-related postulates that inform day-to-day heath care practices. In other words, for EBHS, ‘seeing is believing’ because EBHS carefully limits what can be seen in the first place. EBHS limits not only what can appear within our visual field but also how it will appear and how that evidence will be framed. EBHS appeals to a culture that is taught to embrace simple directives and to be suspicious of intellectual critique.

A more massive strawman it is hard to imagine. Nowhere does it say in EBM that evidence must be “visual, immediate, and incontestable.” What a load of rubbish! If evidence were that obvious, then EBM wouldn’t even be necessary. Certainly that tool of EBM, the meta-analysis, would not be necessary because the very reason to perform a meta-analysis is to try to develop a consensus when there are multiple trials that do not all agree. In fact, EBM can be viewed as a means of trying to make sense of clinical data supporting various treatments, even when the data are not clear or are conflicting. “Seeing is believing?” Ha! If only EBM were that easy! Actually, if EBM were that easy, anyone could do it.

Murray et al then go on to claim that “seeing is not always believing,” taking arguments about the social sciences and invoking, of all things, the Rodney King trial and the videotape evidence used, concluding:

Our point in referring to what many saw as a manifest injustice is to call attention to our ways of seeing and the often hidden politics of the evidence to hand. In the King case, many of us would draw a very different conclusion from the visual ‘evidence’, even though it is exactly the same piece of evidence: it can be repeatedly screened, its accuracy can be independently verified and it can be measured according to standards upon which we can all (presumably) agree. Although the evidence seems to present a truth that is pure and simple, as Oscar Wilde once quipped, the truth is rarely pure and never simple. The evidence cannot simply speak for itself because the meaning of that evidence is of another order altogether. Thus, we must worry about the ways in which evidence is manipulated and contextualised under the aegis of efficiency, in the name of political expediency or in the name of scientific progress, and sometimes all three at once, as in the famous case of the Tuskegee Syphilis Study, to offer one tragic example.

Got it? Because a jury interpreted a videotape in a way that didn’t make sense to most people, that means that EBM is wrong, a false, politicized concept! Truly, you can’t make stuff like this up. At least, no one with a scientific outlook can, except perhaps as parody. Never mind that the jury of the Rodney King trial were not scientists, and it wasn’t the scientific method being applied. Indeed, one reason the scientific method exists is to serve as a check against the very sort of problems in human perception that allow verdicts like that of the Rodney King trial to occur. In fact, I’m surprised they didn’t bring up the O. J. Simpson verdict as well. And, of course, EBM is just like the Tuskegee Syphilis Study, if you’re to believe these twits. Never mind that in addition to being incredibly unethical the Tuskegee Syphilis Study was actually pretty dubious science given that much was already known about the progress of untreated syphilis.

The most hilarious part of this whole article is its defense of Holmes’ previous “microfascism” nonsense. But first, he more or less lays out that his purpose is to politicize EBM:

Our critical perspective develops some of the five shortcomings of the EBM succinctly described by Cohen, et al. (2004), namely, that EBHS [1] relies too heavily on empiricism, [2] relies on too narrow a definition of evidence, [3] ironically, lacks any evidence of its own efficacy, [4] is of limited use for individual patients and [5] threatens the autonomy of the clinician or patient relationship. In addition, however, our work has attempted to politicise the ways of seeing that have become common in the health sciences as a result of the EBM agenda (Holmes, et al., 2008; Holmes, et al., 2006a, Holmes, et al., 2006b; Murray, et al., 2007). In other words, we have sought to examine, to bring to light, the unexamined postulates that underwrite the EBM. From this critical perspective regarding what is now the dominant episteme, we claimed that the EBM was politically dangerous (Holmes, et al., 2006a). Relying on the French philosophers Deleuze and Guattari (1987), we argued polemically that the EBM is akin to a totalitarian political structure and, consequently, that its way-of-seeing is informed by a politically dangerous ideology. In a nutshell, we noted that the EBM wholeheartedly adopts corporate models of efficiency and accountability, right down to a corporate lexicon; EBM relies reductively on quantitative evidence in which RCTs are fetishised; EBM denigrates other forms of knowledge, including clinician experience and patient testimony; finally, EBM evacuates the social and ethical responsibilities that ought to distinguish health care professions, such as nursing.

Of course, what really bugs the authors about EBM is that it values least the type of evidence that they value the most: personal experience, in other words, the kind of “evidence” that supporters of “alternative” medicine value more than anything else. That, and the fact that they don’t like being constrained by EBM, “best practice” guidelines, or anything else. I’ve discussed why the description of EBM above is a load of steaming, stinking, fetid dingos’ kidneys before; so I won’t repeat myself. Suffice it to say that EBM explicitly integrates clinician experience into its guidelines. But the penultimate “triumph” of this article is this:

Unsurprisingly, then, proponents of the EBM have shot back at us, from blogs to journal articles, accusing us of relying on jargon-filled postmodern theories that stand in the way of the EBM’s number one priority, to ‘better man’s lot’, as one commentator put it (Jefferson, 2006, p.393). Indeed, we are charged with a kind of recklessness, a blind and wanton vendetta against the EBM practitioners at the expense of patient health and well-being. At first blush, this is a clever rhetorical strategy. We ivory-tower ‘theorists’ are easily pitted against the ‘practitioners’ when the practitioners are celebrated as nobly serving humanity down in the trenches; thus, according to such a binary logic, we are demonised as theoreticians who ignorantly obstruct those pious practitioners who only want to do their job! Despite EBM’s evangelical rhetoric of salvation, this unrepentant moralising soon betrays its superficiality. In response, we have argued (Murray, et al., 2007) that theory is a kind of practice and that our critical intervention demands of practitioners a certain intellectual integrity and honesty. In fact, this is what should count as ‘good science’ and ‘persuasive evidence’, quite distinct from the ‘state science’ (Foucault, 1997, p.37) that the EBM has become. We demand that they think not only about the means by which better outcomes (an EBM mandate) are justified but also about the wider social and political effects of these means and ends together.

Poor babies. Write nonsense, and of course you can expect some harsh criticism. They also misrepresent the criticisms. In fact, the criticisms were not that Holmes et al were somehow standing in the way of bettering man’s lot through EBM. It was that they were misrepresenting what EBM was, misrepresenting what science was, and, worst of all, representing science and EBM as a form of fascism. If any response was “superficial,” it was theirs. It also reveals that what is most important to the postmodernist is not science but the social and political effects of science. As hilarious as the above jargon is, it pales in comparison to this pièce de résistance:

There is no such thing as a ‘statistically average patient’, and the vast majority of patients cannot accurately be described as white, male, Western or heterosexual, which are increasingly troubled identity categories. Thus, we suggested that ways-of-seeing were epistemic, that is, largely a product of shifting social and historical values. As evidence, we cited the historical pathologisation of homosexuality along with the hysterisation of the female body, both of which are now widely recognised as bad medicine, but designated as Truth in previous years. One way to combat such methodological fundamentalism is what we might call methodological pluralism, where a plurality of discourses and knowledge is encouraged. In this way, we hope to resist the Orwellian ‘Newspeak’ that reigns in the health sciences–buzzwords like ‘best-practice champions’, ‘gold standard’ and ‘spotlight organisations’, which work to ensure a highly normative, uniform and rigidly circumscribed way of seeing, speaking and thinking.

In short, we must find ways to combat the procrustean policies that have hijacked many modes of scientific inquiry and have led instead to a tangled web of ideological apparatuses, including Big Pharma; innumerable government lobbies; professional healthcare associations, such as the Registered Nurses’ Association of Ontario (Canada) and its compulsive endorsement of ‘best-practice guidelines’; academia and its research sponsors; the convergence of research and business with multiple stakeholders, both public and private; paradigms rewarding the bioentrepreneurship of biotech companies; service industries from the human genome sciences to multinational agribusiness complexes; corporate models from the ground up, including accountability practices and the obsession with quantification; the legal-juridical complex; and the insurance industry (Murray, et al., 2007). This list is by no means exhaustive, but it indicates that the challenges are legion. Nothing less than a multitude of micro-resistances is called for in each of these domains. In the face of a strategic fundamentalism that closes off debate, we must be mindful to resist in such a way that we open up critical debate and question those mechanisms that work to seduce us into complacency. In short, the health care sciences ought to work to foster an ethic of patient care that resists technocracy, that is, an ethic that will be respectful of and responsible for patient diversity for the good life (Murray, 2007).

I’m particularly amused by their use of the word “procrustean.” It’s a word I had never heard of before, and, as anyone who reads this blog knows, I have a pretty darned good vocabulary. So I looked it up. The derivation of the word is from Procrustes, a mythical Greek giant who stretched or shortened captives to make them fit his beds, and it’s defined as “producing or designed to produce strict conformity by ruthless or arbitrary means.” In other words, to this PoMo crew EBM, like all good “microfascism” requires absolute “conformity” and enforces it by ruthless means. This is such utter nonsense on so many levels that it’s as breathtaking in its hyperbole as the original “microfascism” article while at the same time being yawn-inducing in its utter tedium. Yes, yes, we know. That nasty science and that nasty EBM construct restrict your freedom to consider any source of evidence you want, no matter how dubious. All this entire attack is is the “health freedom” movement dressed up in incomprehensible “diversity”-promoting PoMo jargon to an even more laughable extreme than their previous articles.

The Four Horsemen of the PoMo-calypse ride again, indeed–at least three of them anyway. Or maybe I should call them the Three Out of Four Horsemen of the Procrustean PoMo-calypse.

The passage cited above is also a typical example of how such people can take the germ of an idea that’s a valid criticism of randomized clinical trials and their importance in EBM made by even advocates of EBM (for example, that RCTs can at times be very difficult to apply to individual patients) and go straight off the deep end with it into a tangle of PoMo gibberish so dense that it defies understanding. I could discern the “science was wrong before” argument so beloved of cranks of all stripes, along with a lot of other logical fallacies. Once again, what matters more than anything else the the Horsemen is the political and social implications; the authors want science to serve their political agenda, not the other way around, because, to the Horsemen at least, EBM must obviously controlled by all the things the they hate, the insurance industry, “bioentrepreneurship” and big pharma, the veritable Roots of All Evil and Threats to Diversity. To achieve their aim of destroying EBM (with a minor concession that there would “still be a role” for RCTs, although the implication is that that role will be small), the whole argument boils down to a predictable appeal to other ways of knowing, in the form of advocating “resisting technocracy” and, above all else, promoting “diversity” (whatever that means).

Of course, to the PoMo quack, “diversity” means nothing more than the freedom to do whatever one wants or to believe whatever one wants, evidence be damned–because, as people like Murray et al tell us, “evidence” is hopelessly corrupted by the power structure, whatever that means. Science is therefore nothing more than another way of knowing, with no inherent superiority to other ways of knowing how nature works or what treatments work the best. Although the Horsemen don’t come out and say it, the implication of their argument is that if a quack believes that liver flukes cause cancer and that zapping the flukes with a cheap electrical device will cure all cancer, who is science or that nasty EBM to say that that’s not true? In any case, two years later, I still stand in awe of the amount of sheer B.S. concentrated into such a brief little paper.

It’s like a black hole of PoMo stupid.