Law & Society Blog

Thanks for J. Carter Wood at Butterflies and Wheels for bringing this gem of an article to greater attention. The title: “Deconstructing the evidence based discourse in health sciences: truth, power and fascism“. Published in the International Journal of Evidence-Based Healthcare, written by health science Profs. David Holmes (also a registered nurse) and Genvieve Rail, PhD candidate / registered nurse Amelie Perron, and English Prof. Stuart Murray.

Yes, you read it right: fascism. In health science.

The really bad kind of fascism, if you will.

The thesis is that what is called “Evidence based health sciences” (or EBHS) is a hegemonic form of discourse. (Hegemony, we’re led to believe, is just another way of saying “fascism”.) The villain, EBHS, involves, well, evidence: taking into account the successes and failures of certain practices, and then acting accordingly. It is alleged that this sort of method is tied to a source of data called the “Cochrane database”, which (we’re told) provides the RN or doctor with information only about the most reliable methods. It is to be contrasted with “pluralistic” visions of the nature of science; the details of these other, marginalized sciences escape me, though empathic understanding (or verstehen) appears to be part of what they have in mind.

I don’t think I can do this thing justice. No matter what I say about it, my words will be but a shell of the experience of reading it. I could be even-measured as a reviewer, but the result would be to interpret sense into a place where there’s a fundamental lack of it; and I could be scornful and mean, if I didn’t sympathize with some of the intuitions that nevertheless inspired the abysmal end product, which deserves no sympathy. (This paper, incidentally, was brought to us in part by the government of Canada, whose SSHRC division’s ostensibly ironic motto is “We build understanding”.)

The first thing that occurs to me is that the thesis commits the common fallacy of blaming a method for one of its uses. The authors seem to blame evidence-based searching for the supposed wrongs of taking the Cochrane database to heart. The database, evidently, only provides the absolutely optimally justified information, the best and most reliable knowledge one can find. The authors state: “One of
the requirements of the Cochrane database is that acceptable research must be based on the [randomized controlled trials] design; all other research, which constitutes 98% of the literature, is deemed scientifically imperfect.” As stated, I see no problem, because there’s no significant normative exclusion involved in presenting the facts as they are. The problem arises when people in the system define the terms of when something is or isn’t actionable, without first taking pains to think of the consequences of what they’re doing.

Now in practice, I can imagine a scenario where this might be an issue. Sometimes, people in authority have a hard time believing that facts about a situation are not especially predictable, and can’t accept that incomplete data (and the risk that accompanies it) may still be far better than rash, random ignorance. When a starving man turns down all meals except fillet mignon, then you know he’s asking to die; and the same applies here. And perhaps (to exercize a bit of verstehen) it is rage with personal experiences with such characters which animated this paper. Fine enough.

But comments about the contingent practices of authoritarian dopes are not to be conflated with the niceties involved with a theory, because (absent any citation to the contrary from the authors) the theory is ambiguous about which data are actionable and which are not.

All of this, we’re told, is “fascist” — actually, “microfascist”. My former political philosophy professor and permanent member of my good books once explained: “In today’s terms, to call someone a “fascist” seems to just mean that you’re a jerk”. I guess that’s what’s going on here, because the old label doesn’t apply; indeed, the idea of “microfascism” is curious, since the entire idea of fascism is to champion a nation-state over an individual, and to devote oneself to its will; a kind of radical collectivism, there’s nothing “micro” about it. And no new definition is provided: rather, we’re given a footnote to Deleuze, and later informed that we’ve already been given a definition. If imagination is a necessary component of nostalgia, then I guess this is a prime example. The only attempts to define that I can see come in rather late in the paper, and say that fascism is “exclusion”. This is about as meiotic as calling a lion a pussycat. And anyway, it doesn’t apply to a mere method: the authors may have a right to aim at the misuses of a certain database, but evidence itself has been caught in the crossfire.

“Crossfire”, you say? Yes, evidently. We’re told that there is a war going on, between the powerful 1984-style elites in the Cochrane group and the ragtag misfits with hearts of gold who endorse the conflationist model of criticism. If the authors took their words seriously, then they’d be in violation of the Hippocratic Oath. One then hopes not to have to be under the knife anywhere in Toronto or Ottawa, where the authors live.

Probably the only interesting remark I derive from this is that a more pluralistic approach to the examination of power would have stalled this tragic essay from ever being written. Power is virtual dependency. Power is not exhausted by the hegemony of an idea, if those hegemonic ideas have simply been persuasively put forward in cooperative conversation. This is especially important when one comes to understand totalitarianism, because hegemony of an idea is merely one source of power, namely, the power of the common mind; while totalitarianism is power which has captured all sources. To conflate a method — which does indeed have hegemony, because it is authentic to a large degree — with the way that some people have decided to use a database, is …

…well, nonsense. It does not compute, does not provoke any mental images, fit into a sensible syllogism; it has no truth-conditions, has no cogency, no role in everyday usage, no consequence on our behavior; no value as an achievement; as a speech-act, it is barely audible; it uses no radial categories, no propositional functions lead us to a lasting moral; it has no content, conforms to no intention, resists interpretation, and hermeneutical study is as ignorant of its sentences as George W. Bush is to Casey Sheehan. In short, it literally, exhaustively, definitely, definitively, and scrupulously makes no sense. The irony (one bit of irony among many) is that one of the very things they want to argue against is the practice of linguistic opaqueness: that is, using words in a way that’s totally out of step with the common lexicon, simply for the purposes of exclusion. But in the process, they only succeed at alienating everyone.

This, then, is a miserable day for the Canadian grant system; and a proud day for the ‘International Journal of Evidence-Based Healthcare’, which has proved its merits most successfully by entertaining opposing arguments which had failed to give the question any serious thought.

It is perhaps no coincidence that my mother is a registered nurse, and it is her job to gather data on patient statistics at her hospital, and to report them to the Canadian government along with various information about treatments. I asked her to read this article, so she can have the last word on the subject. She said: “I don’t understand it. It makes no sense to me, the words didn’t make sense. The only thing that made sense that they said was that you can’t get funding unless you’re doing evidence-based research. But you can call these things whatever name you want, and your point of view might even be valid, but at the end of the day, it’s not going to change anything unless you can show that you’re evaluating things in a rational way. I don’t know if I’m just not smart enough to understand it, or what.”

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