What is the ‘Evidence’ of ‘Evidence Based Medicine’ anyway? This short essay situates a critique of ‘The Philosophy of Evidence Based Medicine’ by Howick J (2010) within continental post structuralism and Western pragmatism.
Howick wrote a book called ‘The Philosophy of Evidence Based Medicine’ in 2010 that is now the basis of a course being run at the Oxford Centre for Evidence Based Medicine, it is a detailed explication of the finer points and conundrums of the logical positivist industry of ‘evidence’ production – the research that tells us whether treatments work or not. Below I suggest that it is naive and perpetuates the harms disseminating from the real-EBM brand, EBM(TM).
Howick’s claim is that of a discourse of the University. It produces ‘subjects-of-science’ who ‘obey orders’ in discourses: the patient as the fuel of the consultation, the engine room driving sales that is the market, the governmental headquarters that is the University and its positivist experts. It is hanging on to the belief that EBM’s evidence is ‘only’ and ‘solely’ what is useful. The Frankfurt school critiqued positivist methodologies, that elevate rational mathematical logic to the status of guarantors of the only truth to be considered, and found it to be reifying (de-humanising, the banality of evil) and creates a psychopathic neosubjectivity. These are features that Horkheimer et al claimed made events like the Holocaust possible. Marketised EBM evidence has resulted in many deaths already. It is well nigh time for the medical community to take a much more sceptical view of EBM-TM and to embrace a more sophisticated media literate analysis of its praxis. The dominance of EBM must be challenged to support a movement to de-medicalise precisely by striving to minimise destruction of the material world by de-industrialising and radically changing our global capitalist political economy.
Pragmatism challenges Howick’s positivist implication that the logics and evidence of EBM should be the sole grounds for believing whether a treatment works. Pragmatism is a major philosophical field. The word is used somewhat differently from its every day use implying sufficient reason for action on practical grounds. It seems to be very close but not the same as a continental post-structuralist philosophy based on Marx/Althusser/Foucault/Lacan: the main difference being the latter’s emphasis on discourse constructing the objects of which it speaks and subjectivity being both a misrecognising desiring/demanding barred subject through and in language and the product of the ensemble of social relations, in dispositifs of power and resistance, domination and subjectivation – in other words a ‘political economy’ socially positioning subjects based on false logics through enterprises and discourses. Such dispositifs include the Evidence Based Medicine brand or movement.
Howick in his book ignores these major western and continental philosophical developments from Marx’s dialectical historical materialism (which rejects both Feuerbach’s crude emprical realism and Hegel’s German idealism) to Dewey’s pragmatism. Pragmatism has been ignored by Howick in his claim that ‘evidence’ is
defined simply as ‘grounds for belief’
whilst truth for pragmatism would claim that an assertion that predicates truth has a property called truth only if the claim is useful to believe. I claim that for EBM its marketised EBM (TM) is totalitarian and becoming increasingly less than useful, even harmful to believe. This is because it is firstly, misleading empirically through market bias (even editors of the Lancet and NEJM claim most research published is even empirically false let alone biased see citations in Williams post on medialens’ website), as well as secondly, epistemologically overblown and naive about the status of its ‘knowledge’. By claiming that its logical positivist ‘evidence’ must be the sole arbiter of ‘treatment effectiveness’ it is in denial of the social construction of the human subject and as a result has become a mere slave to the market’s Master. Howick’s views are based on a Cartesian philosophy that gives thought an original divine primacy, ‘pragmatism’on the other hand would argue thought is the product of organism and environment, not an originary product, or an original ‘given’ for man.
Howick presents the realism of empiricism, (a view of experience as corresponding exactly with a reality out there) in opposition to idealism (mechanistic reasoning) but ignores the possibility of neither being useful, or true, possibilities held by Marx’s dialectical materialism that moves towards a scientific pragmatism that was to come after Marx (see article by Sidney Hook), in which a human nature, as the abstractions produced by our thoughts, changes and emerges as needs must in different historical conjunctures over time.
Pragmatism thinks of epistemology (what can be known) from a coherentist viewpoint rather than correspondence, but rejects a realism philosophy that claims sensationalist (ie through perception through the senses) knowledge represents the reality out there.
So, what is the ‘evidence’ of Evidence Based Medicine’?
‘Evidence’ Latin: ‘e’ ‘ videre’ : ‘what is given out to be seen’ – so rather than being defined as Howick would have it as ‘grounds for belief’ I think this could and should be better defined as what is made (manufactured) to appear; and after Foucault and Lacan, evidence is what is made (constructed) to appear (as ‘superficial appearance’) as the objects made by discourse, precisely what is not superficially self-evident, also always functioning within structures of discourse within dispositifs and their political economies on a (de)-or not de-barred subject, of fantasy and need/desire.
The harms of a marketised EBM(tm) are compounded by the internally set limits that prevents EBM from confronting the aporia the sheer lack of knowing that much testing skirts around, this manifests itself in the mystique and perhaps fetishism of a test’s cut-offs, the point at which pathology is discursively created. The lack of meaning at the heart of screening tests, tests that have uncertainty associated with predicted outcomes (what I have called diachronic predictive tests) is what undermines the applicability of EBM(tm)’s positivistic mathematical probabilistic logic.
The abstractions of thought, the very formations of our ideas, our humanity, what it means to be human, changes as our experiences and needs change with time, historically. This is historical materialism, a rejection and new synthesis of crude realist empiricism and German idealism giving primacy to thought. The subject-object opposition is rejected and becomes a subject-truth opposition. This is what EBM is failing to embrace.