Here we go again. Evidence-based medicine (EBM) has once more come under fire, only this time the accusations are even more brutal. The EBM movement, says a group of academics at the University of Ottawa and the University of Toronto, is "outrageously exclusionary," "dangerously normative," and "a good example of microfascism at play." As an EBM believer, I guess this would make me a microfascist.
The academics, led by Professor Dave Holmes from University of Ottawa's School of Nursing, made their accusations in a dense, jargon-rich paper called Deconstructing the evidence-based discourse in health sciences: truth, power and fascism. It appears in the International Journal of Evidence-based Healthcare.
As you can guess from the title, it's a pretty tough read, full of words like "territorialised," "interpollated," "hegemony," and "post-positivism." In essence, the authors suggest that EBM has become overly dominant within the health sciences and has excluded other ways of thinking about what treatments might work for a patient. Holmes and colleagues say that the language of EBM has become "an ossifying discourse," and that, as the main torch bearers for EBM, the Cochrane Collaboration "supplants all heterogeneous thinking with a singular and totalising ideology."
Archie Cochrane a fascist? The Cochrane Collaboration a totalitarian regime? At first I thought this paper was a spoof. But apparently not. In fact, the former director of the National Institutes of Health, Bernadine Healy, cites the paper in her latest column for US News and World Report, while putting her own boot into EBM ("By anointing only a small sliver of research as best evidence," she writes, "and discarding or devaluing physician judgment and more than 90 percent of the medical literature, patients are forced into a one-size-fits-all straitjacket").
I take a rather dim view of these attacks. It is a fallacy to suggest that EBM forces health professionals to behave like automatons. Indeed, in the classic article Evidence based medicine: what it is and what it isn't, published in the BMJ, David Sackett and colleagues made it clear that EBM involves the “compassionate use of individual patients' predicaments, rights, and preferences in making clinical decisions about their care.” If you get sick, don't you want a doctor to apply the very best evidence on what will work for you as an individual?
The alternative to EBM is a return to the bad old days when doctors used certain treatments because they seemed to make intuitive sense, or because experts told them to, or because observational studies suggested benefits, or because they had seen a case in which the treatment worked. But, as I have previously argued in an essay called Subjectivity can be inhumane, published in wjm, history is littered with treatments that seemed to make sense at the time, but that have now been proven to be useless or, worse still, damaging.
A good example is debriefing for treating psychological trauma. In their Health in Action article in PLoS Medicine, Prathap Tharyan and colleagues describe how, in the wake of the December 2004 Asian tsunami, aid agencies rushed in to offer forms of quick debriefing to survivors. Unfortunately, a Cochrane systematic review on debriefing found no evidence that brief single-session debriefing reduces psychological morbidity. In fact, the review found evidence that those who receive debriefing have a higher risk of developing post-traumatic stress disorder one year later. So it is quite possible that these well-meaning aid agencies ended up causing harm. A systematic review published today in PLoS Medicine found no evidence that any of the treatments given to patients with SARS were effective. And then, of course, there's hormone replacement therapy, tonsillectomies, episiotomies…which, for many patients, were useless or harmful.
I'll leave the last word to the wonderful Ben Goldacre, who writes the Bad Science column in The Guardian. Goldacre points out that Archie Cochrane was "a prisoner of war for four years in Nazi Germany, who has, from his abstracted position, probably saved more lives than any doctor you know." And to Dave Holmes and his coauthors, Goldacre says: "in 1936, he [Cochrane] went to Spain to join the International Brigade, and fight the fascists of General Franco. Now, what did you do with your summer holidays?"