Cochrane, EBM, and fascism, continued

Related to the article I talked about in this post, "Deconstructing the evidence-based discourse in health sciences: truth, power and fascism", Ben Goldacre of the Guardian follows up on an earlier badscience post about the article with another entry, "Archie Cochrane: 'Fascist'."

Excerpt from Goldacre's commentary on the article and on Archie Cochrane:
"...the argument of this paper – bear in mind it’s not an easy read - seems to be that: evidence based medicine rejects anything that isnt a randomised control trial (which is untrue); the Cochrane Library, for some reason, is the chief architect of this project; and lastly, that this constitutes fascism, in some meaning of the word they enjoy (28 times)...

Now firstly, they are plain wrong about the Cochrane Library (which simply produces good reviews of published literature): it does not only use trial data, as they claim, and it is spectacularly ignorant of them to suggest otherwise.

But there is a more important general issue here. Evidence based medicine is widely perceived as being soul-less, and algorithmic: the last thing we’d want from doctors. This is a foolish misunderstanding. EBM is about using quantitative information, in concert with all other forms of knowledge, sensibly, in a clinical context. It does not denigrate other forms of knowledge, like clinical experience or patient preference. It is not about being an automaton. I believe you humanities graduates would call that a “straw man” argument.

Well that’s all a bit sensible: how about some more childish attacks, ideally involving fascism? Okay then. I will wear their label of “fascist” with a cheeky grin. But Archie Cochrane, on the other hand, pioneering epidemiologist, inspiration for the Cochrane Library, a prisoner of war for four years in Nazi Germany (“the main reason for my capture was my inability to swim to Egypt”) who has, from his abstracted position, probably saved more lives than any single doctor you know, might see it a little differently, since in 1936, he dropped out of medical school and travelled to Spain to join the International Brigade, where he fought genuinely violent totalitarian oppression, the fascists of General Franco, with his own two hands. Now. What did you do with your summer holidays? "

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"

- butterfliesandwheels.com "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."

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