Richard Smith: Is evidence based medicine a form of microfascism?

richard_smith_2014My friend Nicholas Christakis recently tweeted: “Critique of evidence based medicine on grounds that it is exclusionary and ‘colonized’” providing a link to the critical article. He added an NB to me, and the result was that I was a witness to a Twitter squall (not quite a storm). Most of the tweeters were appalled by the article, some wondered if it was a spoof along the lines of the “conceptual penis,” a paper made up and recently published in a journal showing both, the authors argued, the emptiness of social science and the hopelessness of peer review.

Nicholas added me perhaps because he thought I’d be amused but also perhaps because he sees me as one of the high priests of evidence based medicine. It’s true that we made great play of evidence based medicine when I was the editor of The BMJ, and at least one opponent of evidence based medicine argued that the cult, as he saw it, flourished only because it was promoted by The BMJ. I was also at the first meeting of the Cochrane Collaboration, the organisation that the article regards as the microfascist leaders of evidence based medicine; and until recently I was the chair of the Cochrane Library Oversight Committee.

What Nicholas may not know is that I think of myself in some ways of having “been through evidence based medicine and come out the other side.” I’ve written a long article with this message that I haven’t got round to publishing. I suppose that I came to feel that it was a little too reductionist and cultish, but I certainly didn’t reject it altogether.

In contrast, the four authors, two of them nurses, from Canada, of “Deconstructing the evidence based discourse in health sciences: truth power and fascism” condemn evidence based medicine absolutely: “we assert that the evidence based movement in health sciences constitutes a good example of microfascism.” They define microfascisms as “polymorphous intolerances that are revealed in more subtle ways [than the macrofascism of Hitler and Mussolini] . . . [but] . . . are nevertheless more pernicious.” The authors of the article “understand fascist logic as a desire to order, hierarchise, control, repress, direct, and impose limits.”

Evidence based medicine has become “a regime of truth.” “One piece of evidence shall count as evidence, while another is denigrated or excluded altogether.” The proponents of evidence based medicine are, they argue, “engaged in a strange process of eliminating some ways of knowing . . . all other research [apart from randomised trials] . . . is deemed scientifically imperfect.” Evidence based medicine “does not allow pluralism unless that pluralism is engineered by the Cochrane hierarchy itself.” It “serves a state or government function . . . [that] can be used to justify cuts in health funding.” It is “an ossifying discourse” that “establishes itself as a weapon used against those who praise the freedom of scientific inquiry and the free debate of ideas [the authors of the article, I assume].”

Evidence based medicine is the tool of “the knowing subject . . . [the clinician] who is “a contextless, abstract, and autonomous ego, implicitly male, white, Western, and heterosexual.”

The authors see themselves as fighting against the microfascism of evidence based medicine: “One of the roles of the intellectual is to decolonise, to deterritorialise the vast field of health science as it is currently mapped out by EBM [evidence based medicine].” The authors quote in their article Michel Foucault, Hannah Arendt, George Orwell, and other French philosophers, all critics of fascism.

Ironically, this paper was published in the International Journal of Evidence Based Healthcare in 2006 and seems to have gone unnoticed until unearthed by Nicholas to evoke a Twitter squall. It has received no citations in Crossref. Indeed, I wondered if the journal either did not exist at all or was a predatory journal, but I discovered that it was published by Wiley but seems to have stopped in 2013. [I was wrong about the article going unnoticed. It’s been cited over 300 times, according to Google Scholar, and evidently has created much debate, showing perhaps how you can evoke a reaction by dramatically overstating your case.]

I can see five reasons why the article fails. Firstly, it was way behind many other criticisms of evidence based medicine. Many other authors made vaguely similar but much calmer criticisms from the very moment that evidence based medicine appeared; indeed, many were published in The BMJ, and there was in fact a considerable and at times intemperate backlash against evidence based medicine. Secondly, the authors’ invocation of fascism is ridiculous. Thirdly, the language of the article reads at times like magnetic poetry. Fourthly, professional philosophers—social epistemologists—have produced much better argued, less inflammatory, more constructive criticisms of evidence based medicine.

But perhaps the biggest fault with their article is that the authors attack not the real evidence based medicine but a chimera they have created. It’s true that systematic reviews concentrate on well done randomised trials to assess the effectiveness of interventions, but Dave Sackett, “the father of evidence based medicine,” always argued that there are many other questions in health apart from “does it work?” and that those other questions need other methods to answer them. The Cochrane Library includes other studies apart from randomised trials and constantly explores new methods. Plus proponents of evidence based medicine have since the very beginning recognised that evidence alone cannot make decisions and that values are just as important.

Then the idea that evidence based medicine is a state tool for cutting health funding is plainly wrong when the National Institute for Health and Clinical Excellence (NICE) of England and Wales, which uses the methods of evidence based medicine, advocates many expensive treatments that the NHS cannot afford to introduce.

Plus evidence based medicine is a democratising not an authoritarian force. The alternative to evidence based medicine is the expert based medicine that prevailed for centuries. With expert based medicine it is impossible for the student nurse to challenge the expert, but the evidence belongs to everybody. In the early days of evidence based medicine students and junior doctors were much more enthusiastic than the experts being displaced; they could examine the evidence and challenge the experts.

I’m glad, however, that Nicholas has brought the attention of many people to the article. It makes amusing reading, constantly making you wonder if it’s a spoof, and it does contain a kernel of truth. Many homeopaths would, for example, approve, but unfortunately the kernel is buried under hyperbole.

Richard Smith was the editor of The BMJ until 2004.

Competing interests: None declared.