It's not every day that you come across an article such as 'Deconstructing the evidence-based discourse in health sciences: truth, power and fascism', which appears in the current issue of the International Journal of Evidence Based Healthcare
. Oh no. This is something special.
The article has already taken a rather good (though comparatively gentle) shellacking from Ben Goldacre
, he of 'Bad Science' fame. (A source, incidentally, which is essential reading for all who want to keep abreast of the latest in anti-scientific tomfoolery.) Goldacre makes some very trenchant points regarding the authors' casual linking of the professional legacy of Archie Cochrane, a veteran of the Spanish Civil War, with 'fascism'. He also ably defends the notion of evidence-based investigation, which, for various reasons, the authors of this 'scholarly article' see as an agent of creeping 'totalitarianism' affecting the health sciences. (I would have thought that any discipline calling itself a 'science' - whether in the singular or plural - would by definition be based on both evidence and reason, but I may thus be showing symptoms of what comrades of an earlier time might have called 'deviationism').
There are, as Goldacre points out, a variety of reasons not to like this article. Some take us beyond the article itself, which is, after all, only a single example of a much wider phenomenon: the alarming spread of irrational and sloppy thinking.
However, my perspective on the article is necessarily different than Goldacre's. I do not have a science degree (nor am I in the medical or health sciences field). I am, in fact, one of those beings much maligned by Goldacre: a humanities graduate. As such, I went through the ritual bathing in postmodern theory which is part of the process of receiving a modern liberal arts doctorate. I have, in fact, cited Foucault in my book on violence. I can use the word 'discourse' correctly in a sentence and can do so without either needing to be ironic or breaking out into laughter. Moreover, I perceive myself to be, in a phrase that for some reason suddenly strikes me as quaint, 'on the left' - where I presume the authors of this article would also locate themselves. Thus, in theory (so to speak), I should be eating up the utterances of the doctors (and near doctor) Holmes, Murray, Perron and Rail. They are, so to say, my sort of people.
It is perhaps for this reason that what they have produced bothers me so much. The frustration and rage which results from being let down by your own side is something with a very distinctive and special kind of sting. You feel it at times such as when Michael Moore depicts Iraq under Saddam Hussein as a happy and prosperous fun park
or when prominent writers and thinkers refer to a viciously anti-Semitic terrorist organisation as a 'resistance'. Perhaps for this reason, this strange little screed has lodged itself in my mind and won't let me go, because it seems to exemplify things which have gone wrong not only on the left but also in the realm of cultural theory. And this, I think, the crux of my irritation with it. In its incoherent ravings about totalitarianism, it discredits two things dear not only to my heart, but to my mind: the scholarly analysis of society and culture as well as the intellectual honour of the left.
It is, thus, an intellectual own-goal of the worst sort. Hence, my aggravation and need to waste my time writing about it.
The argument of this weird rant, such as it is, seems to be that something referred to as the 'evidence based movement in the health sciences' is 'outrageously exclusionary' and 'dangerously normative'. Not only that, but the evidence based health sciences (EBHS) has, in fact, become a 'dominant ideology' which has come to exclude 'other' forms of knowledge. Now, again, I'm not in the health sciences field, so, therefore, my own knowledge of this topic is admittedly limited. (However, as very little time is spent in the article actually talking about health sciences, this might not matter much.)
I'll have to rely, first, on their own definition of the scourge we all face:
As a global term, EBHS...reflects clinical practice based on scientific inquiry. The premise is that if healthcare professionals perform an action, there should be evidence that the action will produce the desired outcomes. These outcomes are desirable because they are believed to be beneficial to patients. (181)
What follows is some description of the 'Cochrane Collaboration', an organisation which has gathered and organised research materials on health issues as a resource for health-care professionals. In particular, Cochrane argues that articles must be based upon 'randomised controlled trials' (RCTs). (According to Goldacre's commentary, their depiction at this point is terribly incomplete and ignorant
, something about which I can't speak, but he does.)
The problem as the authors seem to see it is this: EBHS (with its reliance on RCTs as the 'gold-standard' in evidence) has become canonised as the only form of 'truth' in the health sciences. The authors believe, in contrast, that 'the health sciences ought to promote pluralism - the acceptance of multiple points of view' (181). Additionally, EBHS is being used as a handy tool for cuts in healthcare funding, since it serves the setting of 'goals' and 'targets' (I can feel the chills going down my spine already).
I think that one can follow things fairly reasonably to this point. There is a methodology, which they think is wrong and which is increasingly dominating the health field. It is being employed to cut healthcare funding. OK. Leaving aside the whole fascism label, one might say: interesting start.
Assuming, then, that these are the problems to be addressed, I would have thought a good way forward would have been 1) to explain what other methodologies there are and why they are equal (or even superior) to EBHS and 2) to provide an analysis of the financial and political power struggles over health care funding.
But this is where things begin to get a bit...bizarre. (I suppose one could say that they were already quite bizarre in the introduction, where that whole goofy bit about fascism was introduced, but I don't want to talk about that yet.) Having built up the problem to one of 'fascism' and having described this 'dangerous' hegemonic beast, what is the solution which they present? Mass political organising? Legal action to provide equal consideration of other methods of health-knowledge production? Going to the press? Taking to the barricades? No. The answer to the clear and present danger of fascism
seems to be...wait for it...deconstruction
Now, 'deconstruction' has been subject to all kinds of abuse. Some of it deserved, some of it less so. There are many who think that deconstruction is just a stupid joke played by wacky French theorists on a gullible Anglophone world and who see it as the main culprit in turning the humanities into a factory for unbelievable quantities of unreadable, jargon-ridden nonsense. (Its critics might be surprised to find that some of the people who think this are actually inside the fields of literary and cultural studies, but, it's true.) I have to admit: if my only exposure to deconstruction were articles such as this one, I'd hate it too. Suffice to say - in order to spare a much longer argument - there are better examples of deconstruction in action in other places, by other authors. I think, moreover, that most of its practitioners are content to see it as a useful means of analysing texts without immediately taking it up as a wonder-weapon for undermining the various sinister conspiracies of the world. It is a tool, among others; it is helpful in some cases but not in others.
A screwdriver is a great tool too, but you can't build a whole house with it.
There is, furthermore, quite a lot to be said for the broader notion of 'discourse' (as in culturally-shaped and historically-specific ways of thinking about the world). Some form of 'social constructionism' seems only sensible to me when trying to analyse human societies: people understand their worlds through particular narratives about it, and these narratives are both culturally and historically specific. The ways that people in 17th century Europe or 19th century China or 21st century Baghdad define their values and the basic parameters in which their morality is shaped are different. Culture, to put it simply, matters. Furthermore, science is a discourse (more on this below), and it is undeniable that 'scientific' discourses have been misused (both in the past and in the present) to justify all sorts of unpleasant things. There is also a way in which poorly grounded appeals to 'science' are wrongly used to trump all other arguments without sufficient attention to the assumptions which underlie them. Finally, science does not have the answer to everything.
I think all these things are true. And yet, I think this article is nonsense. Why?One: Regardless of what Deleuze and Guattari say, 'fascism' is not an all-purpose word for Anything Which is Really, Really Bad.
'Fascism' - as a label - is experiencing a real renaissance lately. Usually for the wrong reasons. It seems that the authors at least spent a little time thinking about using this term. As their opening line states: 'We can already hear the objections'. Well, they should have listened a bit more closely...and then left out their nifty turn of phrase. Of course, they don't mean that EBHS is really
like the fascism which comes to mind when you hear the term (you know, like, they don't suggest that epidemiologists are going on torchlight parades, committing genocide and engaging in total war). No, they don't
think that. But what do
It comes right at the beginning, wrapped in what I suppose they imagine to be a rather clever and perhaps even playful postmodern word game:
Although it is associated with specific political systems, this fascism of the masses, as was practiced by Hitler and Mussolini, has today been replaced by a system of microfascisms - polymorphous intolerances that are revealed in more subtle ways. Consequently, although the majority of the current manifestations of fascism are less brutal, they are nevertheless more pernicious. (180, emphasis added)
Let's consider this supposed clarification. My dictionary defines 'pernicious' as 1) 'tending to cause death or serious injury; deadly' 2) 'causing great harm; destructive', or 3) (archaically) as 'evil ; wicked'. OK, we are not more than a hundred words or so into this article and we've already been told that the topic they are to be discussing - which, remember, is using evidence to evaluate the effectiveness of health-care procedures - is 'more pernicious' than the fascism of Mussolini and Hitler
. (While we're at it, why not throw in Franco: why 'privilege' only the best-known and most commonly cited fascists? How dare
they be so normative about fascist crackpots.)
I have to say this again: think about this. Think
Now, if someone makes this sort of claim, I think it is only fair for to expect it to be, shall we say, corroborated
. (What, in any case, does
that mean, exactly: 'less brutal' but 'more pernicious'?) After all, one's expectations get rather seriously raised when one is promised something more pernicious than the SS, the death camps and tens of million deaths.
How disappointing, then, that what follows is actually an intra-disciplinary spat about measuring effectiveness in health care.
There is, of course, a very clear reason for using this kind of language. It does, certainly, get attention. (Responses such as this, admittedly, may simply enable this hunger for attention. I apologise, but I had difficulties broadcasting a sufficiently hostile wall of silence in their direction. A blog post was the second best choice.)
More than merely generating interest, though, such florid prose also sets the stage for a massive dose of self-aggrandizement of this variety:
Critical intellectuals should work towards the creation of a space of freedom (of thought), and as such, they constitute a concrete threat to the current scientific order in EBHS and the health sciences as a whole. It is fair to assert that the critical intellectuals are at 'war' with those who have no regards other than for an evidence-based logic. The war metaphor speaks to the 'critical and theoretical revolt' that is needed to disrupt and resist the fascist order of scientific knowledge development. (185) (Emphasis, emphatically, in original)
Apparently the authors see themselves as part of this critical intellectual project. Rather than doing what other health researchers do - which, I presume, means finding ways of improving health care - the authors instead imagine themselves engaged in a much more exhilarating activity: fomenting (metaphorical) revolution. From their university desks, they can work toward creating 'spaces of freedom', they can take part in 'revolt', they can even engage in 'war'. Oh, how the heart pounds with adrenalin.Two: Specifics are always helpful.
Having set off for war with much fanfare, however, the authors launch their attack on evidence based health sciences without actually confronting them directly. They make much of EBHS (or sometimes EBM - 'Evidence-based medicine', but the difference is never really made clear) as a 'regime of truth' which is based on 'a strange process of eliminating some ways of knowing' (181). Two problems here: this process does not seem to 'eliminate' some ways of knowing but rather to evaluate the effectiveness of treatments based upon a clear (not a 'strange') set of criteria. Second, the authors never identify (not once) the other 'ways of knowing' which might be equal or superior to EBHS for the purpose of finding out the effectiveness of particular medical treatments or procedures. All they do is go on about 'pluralism' of ways of knowing, without suggesting what they might be. ('Do they mean voodoo?' asked my wife when I read parts of this article to her. To be honest, my admittedly non-specialist reading would suggest that they do in fact mean voodoo. Or, if they don't, their approach would deny them any coherent reason for excluding
voodoo, faith healing, crystal-energy or any other variety of charlatanism as part of a the 'pluralist' health science regime they seem to recommend.)
What is 'strange', if anything, is not EBHS's process of eliminating demonstrably ineffective medicine (or, at least not demonstrably effective medicine), but rather the authors' attempt to attack EBHS without ever presenting a single specific instance of how this allegedly sinister, hegemonic means of knowledge production actually comes up short. If it is so all-pervasive and malevolent, then one would think that there's got to be gobs of evidence for this lying about. Nonetheless, in this article, the procedures of EBHS are never critiqued in terms of any clear criteria which could replace it. The only 'evidence' presented that there might be something wrong with EBHS consists of a lot of quotes from a handfull of writers and theorists - none of whom were medical scientists - and a discussion of a well-known novel. (This arduous 'research' was funded by the Research Council of Canada: life is
hard under fascism, isn't it?)
I suppose presenting evidence to back up their arguments would be too...well, evidence-based, wouldn't it?
Nonetheless, say it with me: something is not
true simply because Foucault, Deleuze or Guattari (or Einstein or Newton for that matter) say it is true. Now, repeat ten times.
I have myself used quotes by theorists - it goes with the territory - but it is normally because they express something in a very effective or thought-provoking way. However, such statements are not evidence in themselves
(or, at least, they are not evidence of anything more than that the person in question said them). Foucault, for instance, said some very sensible and important things. He also, at times, talked a lot of rubbish. So it is with prolific thinkers.
And Orwell...I don't even know where to begin on their (mis)use of 1984
. The authors, for instance, seem to be very pleased with themselves about having discovered Newspeak, and they go on about it at length (the better part of a page in a seven page article). But while I can appreciate that they think something similar to Newspeak is now infecting the health sciences field, they seem to miss an important point: in the novel, Newspeak is implemented by a totalitarian state which almost completely controls it population through a variety of other means as well. It is, additionally, a novel,
and (however good it is) it is not evidence - in any way - of the points they're trying to make.
But still, they drone on:
...[A]fter an in-depth reading of 1984, we feel that Orwell's vision is gradually becoming a reality. Currently, a large number of scholars in the health sciences follow their colleagues in medicine down a narrow path leading to uniformity and intolerance. There is therefore in our opinion, the creation and advancement of a new 'language' that is supplanting all others, attempting to discredit or to eliminate them from the discursive terrain of health. This is scientific Newspeak. It is a highly normative and recalcitrant scientific language that stands in opposition to that sense of hope that sustains every freedom-loving individual. (184)
Yes. Things must be looking very grim indeed in Ottawa these days. Of course, it's not as if there hasn't always been a lot of all-too-flippant use of the novel. Some CCTV cameras appear in a train station and some of the more sensitive among us declare we're all suddenly living in a totalitarian state. This is another long digression in the making, but, briefly, I just don't believe that bit about the 'in-depth' reading. Really, I don't, since this is one of the most shallow readings of the novel I've ever seen in print. (Peer-review is just not
what it used to be.) And I think that Orwell - who took rationality, clear thinking and language all very seriously - would be most pissed off to hear his 'vision', his totalitarian nightmare, reduced to something like this.
Along with being someone who went off to fight a frightfully real (and hierarchalising and normativising) version of fascism, Orwell also had quite a few things to say about the malevolent and thought-killing force of jargon and cliché in writing. Lessons the authors could well do with considering. The essay is 'Politics and the English Language'. It is available here
.Three: Knowledge is power...but this a good thing, isn't it?
The authors make what is sadly a common assumption in postmodern writing about science. That is that scientists, rather than primarily being interested in investigating diseases, developing medicines, peering into the universe, cataloguing new species of butterflies or whatever, are mainly engaged in propping up some kind of illegitimate, oppressive political regime. I mean, I think we can be all grown-up enough to avoid idealising 'science' as always merely describing the activity of spotlessly moral people engaged in the disinterested pursuit of truth. But the scientific method, evidence and reason, I think one would have to say, are about the best means this clever sort of primate has come up with for understanding its world. They have led to astounding improvements (and, yes, some very real new-fangled problems) in human life.
Furthermore, there is nothing inherently contradictory between some versions of social constructionism and science. After all, recognising that all ways of knowing are 'discourses' is not the same as the relativist claim that all discourses are equally valid. For some purposes, certain ways of knowing are better than others. Sometimes far better. This is something the authors seem to deny, however. Ignoring the possibility that EBHS is becoming dominant because it is better (again, it's not my field, but even as an outsider, it seems clear that this possibility is likely), they see it simply as part of an imperialist ('colonising') intellectual power-grab.
The solution for the 'problem' they've invented is this:
A starting point for health sciences would be to promote the multiplicity of what Foucault describes as subjugated forms of knowledge (savoirs assujettis): these forms of knowledge are ways of understanding the world that are 'disqualified as non-conceptual knowledges, as insufficiently elaborated knowledges: naïve knowledges, hierarchically inferior knowledges, [and] knowledges that are below the required level of erudition or scientificity' (p. 7). These forms of knowledge arise from below, as it were, in contradistinction to the top-down approach that characterises the hegemonic thrust of EBHS. For Foucault, a subjugated knowledge is not the same thing as 'common sense'. Instead, it is 'a particular knowledge, a knowledge that is local, regional, or differential' (pp. 7-8). (183)
Now, I think there's all kind of value (and sweet sugary goodness) in many forms of diversity and 'pluralism'. But there are times when I don't have so much of a problem with a hierarchy of discourses. One of them is when I'm being operated upon. In that circumstance, I want one 'particular', proven and - give it to me - evidence-based discourse to be appealed to by the person who cuts me open.
If it is effective, I do not mind - in fact I demand
- that it becomes hegemonic.
Whatever the ubiquity of discourses, the idea that they are all equal is a profoundly stupid and obviously false one. Richard Dawkins put it most famously, correctly and pithily (originally in River Out of Eden
, but the version I have is in The Devil's Chaplain
Show me a cultural relativist at 30,000 feet and I'll show you a hypocrite...If you are flying to an international congress of anthropologists or literary critics, the reason you will probably get there - the reason you don't plummet into a ploughed field - is that a lot of Western scientifically trained engineers have got their sums right. (18)
But the attitude of the authors of this article reflects a peculiar and long-extant postmodern obsession with 'pluralism', regardless of whether it is really appropriate in a certain context. Indeed, they are positively absolutist on the issue of pluralism. A decade ago, Terry Eagleton took this particular issue up in his book The Illusions of Postmodernism
. He noted that postmodern theorists
would seem to imagine that difference, variability and heterogeneity are 'absolute' goods, and it is a position I have long held myself. It has always struck me as unduly impoverishing of British social life that we can muster a mere two or three fascist parties. [Note: Eagleton, like Arendt and Orwell before him, is referring to the real kind of fascism, not its allegedly more pernicious and polymorphously intolerant micro-variety.] We also seem stuck with far too few social classes, whereas if the postmodern imperative to multiply differences were to be taken literally we should strive to breed as many more of them as we could, say two or three new bourgeoisies and a fresh clutch of landowning aristocracies.
The opinion that plurality is a good in itself is emptily formalistic and alarmingly unhistorical. (127)
I think that this is something that Foucault himself - who was interested in history even if he was at times a rather bad historian - would have understood. While Foucault very often focused on the dominance which some discourses achieved without having any more essential truth value than others (so, simply as a result of social power), I don't think there's anything in what I've read by him which suggests that he thought there is no way of evaluating discourses based on their correspondence with reality. (And if he did say this, he was wrong on that point.) He might often, for instance, have condemned the ways in which hierarchies were formed; however, stating that hierarchies themselves are a bad thing is quite another step, and one which, I think, he did not make.
Furthermore, without intellectual hierarchies (though alternative ones), and without norms (though different ones) what tools does a 'resistance' have?
Any effective political movement has always understood this. Which brings me to my final point.
Four: Fighting pretend problems with pretend politics.
There is an assumption often made that this kind of postmodernist thinking is in some way 'left-wing' or radical. This is a mistake. What makes it difficult to recognise as such is that it is a mistake which is often made by the same people who put this sort of thing forward. They seem to think they are radical. But beyond throwing around some ill-judged and hard-to-digest verbiage, what political relevance do their arguments have? I mean, the authors of this article seem to think that deconstruction is the primary weapon against the fascist menace they depict. This point, too deserves some consideration.
If it were true that the problem we face is fascism, I would suggest that deconstruction is not exactly going to help us much. Fascism is physically violent and scary. Deconstruction - whatever its merits - is...a method of textual analysis. Outside of a text, it's not going to protect you. Staring down real fascism requires other means.
Woody Allen made this point far more amusingly long ago. In his film Manhattan, the following discussion takes place among a group of intellectuals:
Allen: Has anybody read that Nazis are gonna march in New Jersey, you know? I read this in the newspaper. We should go down there, get some guys together, you know, get some bricks and baseball bats and really explain things to 'em.
Man: There was this devastating satirical piece on that on the op-ed page of the Times. It is devastating.
Allen: Well, well, a satirical piece in the Times is one thing, but bricks and baseball bats really gets right to the point, I think.
Woman: Oh, but really biting satire is always better than physical force.
Allen: No, physical force is always better with Nazis, 'cause it's hard to satirize a guy with shiny boots.
Fortunately, as I think is clear, we are not facing a real fascist crisis in the health services. Perhaps even the authors would agree. They might say that the fascism they identify is purely metaphorical. To which I would respond: given the variety of problems facing the world today (including the very real problem of effectively managing health care systems), is pursuing a metaphorical revolt against a metaphorical fascism really the most productive way of spending one's time?
Nevertheless, with breathtaking self-regard, they cite Hannah Arendt's Human Condition for guidance to 'combat totalitarianism'. (I mean, think what you will about Arendt's views on totalitarianism and whatever else, but at least she was writing about the real deal.) The stakes are indeed high, as the authors thunderously proclaim:
When the pluralism of free speech is extinguished, speech as such is no longer meaningful; what follows is terror, a totalitarian violence. We must resist the totalitarian program - a program that collapses words and things, a program that thwarts all invention, a program that robs us of justice, of our meaningful place in the world, and of the future that is ours to forge together. (185)
They are, indeed, people who will spare no sacrifice in facing down 'totalitarian violence'. They have received their research funding. They have issued their call to arms (or at least their call to words). They are on the front lines of resistance to fascism ('polymorphous intolerance' division). And where is one of the key hot zones where this conflict being fought? Yes, you guessed it. In Ontario
Part of me can't help thinking that if they're so bored with their own field that they need to invent violent fantasies of fascism and resistance to make it interesting, they should perhaps choose a different profession.
But not as writers. Please, no.