Routledge has just published this new book.
I have been researching and writing this over the past ten years or so. By way of knowledge and so called ‘expertise’, I have experience as a UK GP, of teaching, and of some health services research, and an MSc in Health Sciences and Clinical Evaluation.
The book addresses the anticipatory care paradox: the way in which, in the Western World at least, the continuing expansion of anticipatory care – such as population based cancer screening programmes that are promoted in the name of doing good – is in fact causing increasing harms to the capacity to care with love, individual health, and to overall healthcare service accessibility and effectiveness.
For a link to the publishers site and a list of the contents go to:
The book is written in a clear accessible style and avoids arcane jargon as far as possible. It is aimed at undergraduate and postgraduate students of healthcare, and healthcare practitioners, as well as educators of evidence based critical appraisal research, methods and implementation – including those addressing the problems of industry bias, eminence based medicine, overdiagnosis and shared decision-making.
This book is highly recommended as a tool for evidence based heathcare education. It introduces, and explains clearly, with case histories, radically new, but crucial concepts for the way anticipatory healthcare interacts with a) science, b) politics and c) our values, in the real world. This is a book for real EBM. It goes beyond empirical science: the how and the what of EBM, and the harms of medicalisation, to address why the human condition is vulnerable to oppressive ideologies and sustains the anticipatory care paradox. The book, then, is able to point us towards still partial, but, at least, more emancipatory solutions.
The book challenges the apparently self-evident good sense of the idea that early diagnosis by population based screening saves lives and is a good thing. As an alternative the emphasis is, instead, shifted towards a healthcare model that aims to protect the individual from apparently knowing interventions, and, at the same time, to liberate the individual’s unknown capacity to self-actualise his or her own optimal potential for health.
The book asks: a) how and why are powerful medical elites wedded to a pragmatist version of science that decide what effects of care should determine anticipatory healthcare public policy and guidelines and b) why do practitioners and the public alike find such guidelines acceptable, and even desirable?
To address these questions the book moves beyond the science of EBM, to use three additional sites of knowledge production and meaning making. These are sites of: a) political-economic sensibility: that sees capitalist structures and relations as inherently mesmeric and potentially exploitative; b) epistemic (knowledge/truth forming) sensibility: that sees how expert elites use the combination of empirical science andlanguage to shape social beliefs by transforming the meanings of the effects of anticipatory care to: (i) promote the meaning of intended effects to market interventions, and (ii) demote the meaning of collateral harms as harms, that might restrict marketability; and c) psychoanalytic sensibility: that sees the human condition as always embedded within socially produced belief systems, and thereby always vulnerable to exploitation because of its search for, and the necessity to construct, its own values and identity.
The book identifies a series of collateral harms, that, taken together, cast huge doubt on the healthcare value, and acceptability of the vast majority, at least, of population based anticipatory diagnostic interventions and care.
In brief, the book identifies six major forms of collateral harms, these are: a) the exploitation of individual desire for commodities of this kind by using persuasive rhetoric that incites fear, de-values harms, and promises much, and which, in the end, becomes coercive, b) the impossibility that the fact of over-diagnosis can ever individually be adequately valued as the harm it actually is. This is because overdiagnosis is never personally experienced, or imaginable as a harm by any one individual – this means that recourse to providing information of the scale of overdiagnosis as a means of suggesting that the shared decision making process is fair is actually simply cover for an insidiously anti-democratic process, c) the continued diversion of limited financial resources to new forms of anticipatory care that is slowly crippling the capacity of carers to respond with interpersonal love to present day suffering, d) individual financial toxicity in places where there is very limited publicly funded healthcare as in, for example, the USA, e) the depersonalisation of inter-personal caring in a system that incites ever more zealous, even perverse, commitment to meeting screening uptake targets as if for the target’s sake, and f) the unknown, but very likely, and unpredictable harms of medical interventions on the delicate ecosystems of the total-individual, mind and body, to respond to life’s tribulations, and to auto-correct, re-set, self actualise and maximise his or her own health on an ongoing basis.
If there is a call for action here, it is simply: a) to educate future and present health carers about these sensibilities and harms, b) to ask individuals, carers and the public at large, to consider re-evaluating their trust, faith and belief in the elite expert authority and institutions that warrant this form of care and these harms, and c) ultimately, to question whether the vast majority of population based anticipatory care is really a good thing.
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