Evidence-Based Medicine: Does It Appear to be Fascistic?

Recently, an essay published on International Journal of Evidence-Based Healthcare (2006, 4, 180–186) entitled Deconstructing the Evidence-Based Discourse in Health Sciences: Truth, Power and Fascism has provoked a wide range of reactions^†, maily because the authors, Dave Holmes et al., is thought to unilaterally described the Evidence-Based Medicine/Movement (EBM) as an exclusive and normative hegamony in health science, and boldly related EBM to fascism.

The EBM controversies

One of the requirements of the Cochrane database is that acceptable research must be based on the RCT design; all other research, which constitutes 98% of the literature, is deemed scientifically imperfect.

EBM and its related concepts are highly promoted in academic spheres, so much so that a research article free from these taken-for-granted concepts risks being labelled as scientifically unsound.

When only one method of knowledge production is promoted and validated, the implication is that health sciences are gradually reduced to EBHS.

The clinician can often be considered such an institutional subject who is presumed both to know the truth of disease and to have the moral and intellectual authority to prescribe treatment...the authority of the clinician must be understood as a discursive power that shapes the realm of the possible and, in doing so, often ignores certain symptoms that would allow a more appropriate diagnoisis.

--Deconstructing the Evidence-Based Discourse in Health Sciences: Truth, Power and Fascism

The authors' comments cited above, although extreme, represent the common misunderstanding of EBM both amoung its supporters and opponents. They tend to regard EBM as a new principle that have never been in the development of medicine and health science, and in the same time, simplified the EBM concept as limited number of adviced clinical methods. I'm not a doctor or clinician and know only little about medical and health science. As I know, however, modern medicine is an exact science like physics and chemistry which share the same philosophy of materialism. There is no one as ridiculous as to address a new 'Evidence-Based Physics' or 'Evidence-Based Chemistry' in the late 20th century - the time when 'Evidence-Based Medicine' was actually first put forward. It sounds as unbelievable as to saying that the medicine before EBM is not evidence-based. Furthermore with those propagandized methods as Radomized Controlled Trials (RCTs), meta-analysis and systematic reviews, it seems that EBM is nothing but using these method to replace all the rest developed from the beginning of medical science, which is also nonsensical.

In fact the development of medical knowledge is, as it was, always evidence-based no matter we contrivedly emphasize this or not. The reason for the advocacy of EBM, however, may lies in more pratical sense in the daily clinical confrontation which all clinicians have inevitably been suffered. For instance, how to optimize the deployment of limited medical resources in order to provide for the public with better healthcare services? How to make the simple but crucial decision as to which plan to operate on the patient, considering a huge amount of information including the involvement of medical principles as well as both the physical status and the subjective will of the patient? How to choose amoung many which medical paper to accept when it comes to editorship? What's the basic of judging these kind of problems? ... Thus the concept EBM is there to answer these question. Although the defination of EBM is remarkably diverse, its general idea may safely be concluded as the pursuit of making the best decisions based on the best evidences, while the subjugated definations of 'the best' decisions and evidence is yet to be consented. In the current concept of EBM, a good clinical decision, no matter how it is made, should always be the integration of not only medical knowledge, but also the economic situation and the will of the patient, the related insurance company and other organizations, sometimes plus the involvement of laws and regulations, moral and ethical consideration, etc. Therefore the range of 'evidences' is much wider than the conventional expectations. EBM is not a discipline, nor is it a methodology. It does not necessarily mean the utilization of Randomized Controlled Trials (RCTs), meta-analysis, systematic review, or Cochrane Collabration. It is just a way of thinking. These methods are advocated by EBM only because they are believed to be able to provide the most reliable scientific evidences with no or little biases. In fact, these methods should be implemented only when the clinician cannot answer the question of decision with his or her knowledge. There is no need to conduct, say, full systematic reviews during every clinical pratise. Neither does EBM judge the erudition of medical researches. All it concerns, again, is the pratical clinical decision. The health science as a whole will not be reduced to only EBM as is predicted by the authors, and those researches will not regarded as scientifically unsound only because absense of EBM method. They might take lower positions, however, in the evidence for daily clinical decision than those providing EBM results.

† For example: Martin Rundkvist's post: Truth, Power, Fascism and Silly Buggersin in his blog; PZ Mayer's post: Would you let Foucault or Derrida treat your cancer? in his blog; John Timmer's essay: Surely they're joking on Nobel Intent.