Wednesday, August 16, 2006

Evidence-based medicine as a form of fascism?

Holmes D, Murray SJ, Perron A, Rail G. Deconstructing the evidence-based discourse in health sciences: truth, power and fascism. Int J Evid Based Healthc 2006;4:180-6.
Very interesting article which attempts to deconstruct evidence-based medicine to expose it as a "fascist structure." The authors seem to provide a very limited representation of the EBM concept and how it is operationalized in the clinical arena, focusing on the Cochrane Collaboration and its practices as the embodiment of EBM.

In addition to its fairly inflammatory language and sweeping generalizations, the paper also seems to lack any true grounding in knowledge of clinical medicine or practice which might make it more convincing. The paper has a number of great phrases, referring to EBM as a process of "ossifying discourse" and a "regime of truth" and promoting a "vigilant resistance...from within the health disciplines themselves."

The links below provide further commentary on this piece and examples of other articles considering criticisms of EBM.

Commentary on the article:
- Nobel Intent blog: "Surely they're joking"

- badscience blog

- Salto sobrius blog: "Truth, power, fascism and silly buggers"

- "It's a trick, right?"

Related articles:
Barry CA. The role of evidence in alternative medicine: contrasting biomedical and anthropological approaches. Soc Sci Med. 2006 Jun;62(11):2646-57.
"The growth of alternative medicine and its insurgence into the realms of the biomedical system raises a number of questions about the nature of evidence. Calls for ‘gold standard’ randomised controlled trial evidence, by both biomedical and political establishments, to legitimise the integration of alternative medicine into healthcare systems, can be interpreted as deeply political. In this paper, the supposed objectivity of scientific, biomedical forms of evidence is questioned through an illumination of the multiple rhetorics embedded in the evidence-based medicine phenomenon, both within biomedicine itself and in calls for its use to evaluate alternative therapeutic systems."

Kagan AR, Burchette RJ, Iganej S. The case for case reports: avoiding statistical seduction. Am J Clin Oncol. 2006 Aug;29(4):325-7.
"...searching for the single best treatment, when no single treatment works for all patients, leads to a sort of intellectual tyranny that has numerous names: the gold standard, the community standard, best practice, and evidence-based medicine (EBM), with the implication that to take an alternative management route is substandard and unethical."

Gerber A, Lauterbach KW. Evidence-based medicine: why do opponents and proponents use the same arguments?Health Care Anal. 2005 Mar;13(1):59-71.
"...both opponents and proponents rely on different notions of autonomy and free judgment in their argument."

Brody H, Miller FG, Bogdan-Lovis E. Evidence-based medicine: watching out for its friends. Perspect Biol Med. 2005 Autumn;48(4):570-84.
"The activities of three categories of so-called friends might well give EBM an undesirable reputation. These "friends" are the practitioners of a crude version of EBM (uncritical acceptance of randomized controlled trials while rejecting all other forms of evidence), commercial sponsors of clinical trials whose biases distort the available evidentiary base, and bureaucrats who employ EBM practices in the service of inequitable rationing of health resources."

More commentary on the Holmes article and on EBM at Respectful Insolence - "Damn those microfascists demanding evidence-based medicine!"

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At 2:33 PM, Anonymous Anonymous said...

EBM may, or may not, be fascist (I find the term overused). However, it has a power - exemplified by Cochrane. In fact Archie Cochrane has become a diety. I know a number of people who worked with him and suggest his name has become bigger than he ever was. (Read Bruno Latour's Pasteurization of France for a strikingly similar story).

I have worked for and alongside the Cochrane Collaboration. As hinted at by my use of the term 'diety' I believe Cochrane/EBM is more like a religion with numerous priests who help define the belief system.

Much of EBM is based on faith. Given the huge status of EBM/Cochrane there is a woeful lack of 'evidence' that EBM has produced any great benefit (other than to those in the 'pay' of it e.g. clinical epidemiologists, information 'scientists' etc). It is one thing to say Drug A is better than drug B in an RCT but it is entirely another to suggest EBM (as a movement) has made a significant impact on patient outcomes.

A challenge - find me a large scale trial that has shown that clinicians practicing EBM have produced better outcomes for their patients that 'usual' care.

At 5:21 PM, Blogger BeckyJ said...

I think one main issue with the Cochrane Collaboration as it relates to the practice of EBM is that the scope of the covered topics, understandably, does not cover every imaginable topic or practice situation that may occur. Your comments and the original article make interesting points about how the group and its founder have been perceived and possible ideological aspects of this aspect of the EBM "movement."

The way that individuals and organizations interpret the concept of EBM has also evolved as it has gained prominence -- while the original definition focused primarily on incorporating scientific evidence into the practice of clinical medicine, subsequent interpretations and definitions have been extended to include two other key "viewpoints" to moderate and adapt the application of evidence -- that of the clinician and his/her own expertise, and the desires and values of the patient. Rather than a "cookbook" approach to medicine, which is one common criticism of EBM, this way of viewing the concept allows for more flexibility of the model, customizing to each clinical situation rather than a dictated approach that is intended to apply to all.

It is no doubt that EBM has lead to increased interest in professionals gaining skills in research design, statistical analysis techniques, and strategies for finding and critiquing available evidence -- while the interest may be prompted by EBM for some, these issues are arguably key to the entire scientific method that has been prompting investigations for centuries, rather than unique to proponents of EBM.

Regarding evidence that EBM actually "works"--I think evaluating the entire spectrum of EBM would be difficult to evaluate in any one trial, but there are a number of examples in the literature of ways in which systematizing practices, incorporating the best evidence along with clinician expertise and patient values, have led to changes in proximal patient outcomes (e.g. length of stay, days on the ventilator, measures of quality of life and patient satisfaction). A rough search in PubMed provides a few examples.

As a philosophy or guiding principle for the practice of medicine by individuals and by organizations/institutions, I think EBM makes a lot of sense--looking at what has been tried in the literature, what has been proven to work in some situations, what seems to be ineffective or even harmful, and then incorporating these issues in with clinical judgment and patient factors -- the literature or the evidence isn't an "end" but rather part of the path to informed decision-making.


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