Care is required because the EBM methodology and rationale reinforces the maximalist mindset
It is natural and makes sense to want to improve medical practice. And it seems to make perfect sense to want to intensify the application of the scientific method and EBM methodology to the problem of misdiagnosis. However, isn’t the sheer rationality of this quite scary, quite inhuman, as if beyond care?
This positivist EBM methodology has the same rationale that has led us from Halstead’s mastectomies, to national breast cancer screening programmes to Oncotype DX. And it is this EBM methodology and rationale that produces more interventions for the market. This reinforces the maximalist mindset that functions for capitalism to increase the economic productivity of life itself. But what is the aim of this EBM rationale today? Is EBM derived innovation aimed at reducing levels of iatrogenic harms already in existence, a damage limitation exercise, or to provide care that is harmless, or to make us live longer?
Remember that the policies of national screening, early referral, and predictive diagnostic interventions are aimed at prolonging, or to use the rhetoric, saving, life. They are the biggest cause of misdiagnosis and harm and, like austerity, are a matter of politicised choice. This preventive medicine is imposed upon the well. This kind of care goes beyond care. It is not the imperative, must do, kind of care for the present day suffering of the already unwell.
There are ways to use EBM to reduce iatrogenic harm and improve care.
Firstly, would be to actively identify and disinvest in flawed EBM practices, and not only, but especially, the least cost-effective.(Culyer et al, 2007) Flawed EBM practices would be those that fail to reach a much higher imposed burden of proof of benefit than currently exists. No longer imposed on the basis of possibilities, as with e.g. the UK NHS breast cancer screening programme (Baum, 2013), but instead ‘not commissioned til proven beneficial beyond reasonable doubt’.
This would, secondly, increase the options available to re-invest in re-commissioning care that works (e.g. mental health services for the young, palliative care etc) and for practitioners to communicate with people.
Thirdly, the pressure to do this will be helped by insisting the teaching of EBM always includes a real world module on ideology and biopolitical theory. This would be Real Education for Real EBM, teaching the student practitioners about the way ‘the social’ interacts with real EBM’s most crucial object, namely, the diagnosis, and how capitalist ideology creates the maximalist mindset (Horton, 2017).
Baum, M. (2013) The Marmot report: accepting the poisoned chalice. British Journal of Cancer (2013) 00, 1-2, 00: 1-2.
Culyer, A., McCabe, C., Briggs, A., Claxton, K., Buxton, M., & Akehurst, R. (2007) Searching for a threshold, not setting one: The role of the National Institute for Health and Clinical Excellence. Journal of Health Services Research and Policy, 12(1): 3.
Horton, R. (2017) Offline: The Donald Trump Promise. The Lancet, 389(10087): 2360.