The so-called crisis of Evidence Based Medicine, it’s apparent exploitation by Capital causing over treatment is generally attributed to a nasty greedy misuse of the science, so that the ‘evidence’ itself is deemed to be faultless. And some have expressed frustration and a sense of helplessness. As a rule the EBM world pays lip service to ‘sociological approaches’ that try to see the patients care in holistic terms and to shared decision making, to limit coercion by industry. The EBM world tends to be ‘techie’ with a nerd like fascination with its maths, and derides suggestions that we may be subjects that are more ‘deceived slaves’ than ‘free masters’. In response to a recent thread I’ve posted this to the EBM Mailbase list, an academic forum. So it will be interesting to see if there is any response.
EBM’s Moral Law:
I’m a UK GP now working in substance misuse, and have a background steeped in EBM , though less illustriously than JI, and I remember feeling ridiculed when I raised concerns in the 1990s at an educational conference on EBM in Oxford, where I was a tutor, about how to practice honest risk communication in UK general practice. This was deemed to be the GP’s problem and ‘not’ to be the epidemiologist’s problem.
Since then my disillusionment with EBM epidemiology has been deepened over the years by its legitimisation of intensifying public health preventive regimes such as cancer screening, health checks etc that intensify overdiagnosis, and EBM’s (ironically) patent opacity (it’s obvious ability to obscure its inherent uncertainties).
For several years I’ve been exploring what might be called critical theoretical approaches to try to understand what ‘makes good people do bad things’, and focusing on screening and prognostic diagnostic technologies relating to cancer.
For me the most important limiting factor may be how ‘Medical Practice’ can escape EBM’s ‘moral’ stance based upon its monogamous relationship with a (essentially capitalist and Cartesian) mathematicised empiricism and start an affair with politics, Marx, psychoanalysis, subjectivity, power, and fantasy.
These alternative theoretical approaches suggest that EBM hasn’t been hijacked; instead they would suggest that from its inception EBM has fetishised (excessively valued) empirical knowledge as part of a process (in a capitalist historical epoch) that ‘must’ create ‘biological difference’ (through use and exchange values eg through diagnosis) to produce surplus value (extension of life) that accepts as ethical and moral that man, woman and the body can be exploited for profit (by others) of either the economic or semantic kind – [a semantic ‘surplus value’ might be for example where the excessive valuation – fetishisation – of meaning of the word ‘cancer’ has evoked both obedient fear and a funding/research cascade].
EBM’s Moral Law might be expressed as: the justified exploitation of life through prognostic diagnosis to create surplus value out of life – this, is in other words, the ideology of a capitalist EBM, which is also a non-philosophy in that it’s truth is based on a dogma, and it’s exploitation hidden behind the fantasy belief in objective (and economised) empirical knowledge as the sole source of the truth that should guide medicine. At the same time, invoking expertise, as EBM does to reassure the sceptics, just adds to the problem as it is reinforcing the illusion that the expert is a ‘free master’ and not also a slave to this objective knowledge.
EBM’s crisis (in preventive medicine most acutely) is more fundamental than just financial invested interests (although these have a role to play). It is steeped in capitalist normative regimes that rely on unlimited growth and can only persist through ever intensifying and destructive exploitations of the body by ever more penetrative diagnostic and bio-racist technologies. EBM’s crisis also relies upon a subjectivity / a set of beliefs if you like/ that has to deny the possibility of mutual ownership (welfare, socialism), and that imagines him/herself to be a free master of his/her own decision making rather than a ‘deceived slave’ , and that believes his/her life can be extended and extended perhaps forever. Just as I do myself.
EBM, like gender, is a performative discourse, in other words, as a productive capitalist mechanism it enforces and normalises bio-racist roles and exploitative practices. The ideas of critical theory that links Marx with psychoanalysis and a theory of language as discursive power are used extensively by social theorists, feminists, queer theorists, colonial and post colonial theorists and political theorists. I believe medical practice also requires critical theorising, and critical discourse analysis as a (politically active) resistive intervention.
I have attempted to introduce these ideas to a (scientific) conference on overdiagnosis before but was rejected, as ‘not relevant’ – well it’s highly relevant. So I’ll try again and fail again no doubt , but fail better.