Not long ago I commented on a paper by Christine Barry of Britain. Now, from the other side of the Atlantic, comes an even worse paper. The article is “Deconstructing the evidence-based discourse in health sciences: truth, power, and fascism,” by Dave Holmes, Stuart J Murray, Amélie Perron, and Genevieve Rail. You can find it on its official website via IngentaConnect, but you have to pay $52.23 plus tax for access. There are quite a few sites now hosting the paper for free, which violates copyright, but then, since when did fighting fascism involve demanding payment for publicly-funded research papers?

So why is this paper worse? Well, for a start, it shares Barry’s anti-rationalism and her gleeful wallowing in stupidity, but it goes further in labelling evidence-based medicine a form of fascism (no, I’m not making that up), and unlike Barry, who misrepresented a sequence of correspondence, these authors misrepresent so many things that they seem to be making it up as they go along. Plus, Barry wrote her own paper all by herself, where this took four authors. And finally, this paper is worse because the lead author is Associate Professor of Nursing at the University of Ottawa. That is, he teaches nurses. One wonders if he has any interest in teaching nurses about nursing, or whether he prefers to feed them particularly muddled Foucaultian analysis.

The title of another of Holmes’s papers is instructive: Holmes, D., Perron, A., & O’Byrne, P. (2006). Evidence, Virulence, and the Disappearance of Nursing Knowledge: A Critique of the Evidence-Based Dogma. Worldviews on Evidence-Based Nursing, 3 (3), 1-8.

Read that again: “Evidence, Virulence, and the Disappearing of Nursing Knowledge: A Critique of the Evidence-Based Dogma.” It should come as no surprise that Holmes doesn’t have the wit to understand that “evidence-based dogma” is about as sensible as “opaquely transparent” or “orbital submarine.” After all, his use of “fascism” indicates that he doesn’t care much about using language to convey meaning. But more than that, look at the assumption behind his title. To Holmes, evidence-based medicine is “virulent” because it causes the “disappearance of nursing knowledge.” Apparently the quality of that nursing knowledge is not important. If a nursing technique is shown to be useless, or even harmful, it seems that Holmes’s advice would be that it must continue to be used anyway. It is more important to preserve knowledge, even wrong knowledge, than to provide the best available care to patients. Surgeons are no longer trained in the art of prefrontal lobotomy to treat schizophrenia, even though Egas Moniz won the 1949 Nobel Prize for the technique — and this, by the way, was a technique that worked. The knowledge behind it is not incorrect, merely unnecessary with modern treatment. In extremely rare refractory cases of schizophrenia, lobotomies are still performed, but the modern techniques are far more precise than 50 years ago. Would Holmes really want a neurosurgeon today to perform classic Moniz procedures just because they represent a form of knowledge?

There have been a number of responses to the “fascism” article. The very best I’ve read is this one from J. Carter Wood. It is a wonderful analysis of everything that is wrong with the paper’s logic. It is quite long, but its headings make a very good summary. Here is a very heavily edited excerpt of the paper. (Contrary to standard practice, I’ve left out all the many ellipses to preserve readability.)

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. 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 an example of a phenomenon which is ‘more pernicious’ than the fascism of Mussolini and Hitler.

I have to say this again: think about this. Think about it.

After all, one’s expectations get rather seriously raised when one is promised something more pernicious than street battles, the SS, the death camps and tens of millions of war dead.

Two: Specifics are always helpful.

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 handful of writers and theorists - none of whom were medical scientists - and a discussion of a well-known novel.

Three: Knowledge is power…but that’s 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 propping up some kind of illegitimate, oppressive political regime.

Four: Fighting pretend problems with pretend politics.

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.

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 healthcare systems), is pursuing a metaphorical revolt against a metaphorical fascism really the most productive way of spending one’s time?

The organisation that takes the most stick in this paper is the Cochrane Collaboration, but as Ben Goldacre points out in the Guardian, the Cochrane Collaboration is based on the life work, and is named after, Archie Cochrane. But Cochrane was no fascist. He served against the fascists in the Spanish Civil War. Of course, we shouldn’t expect much of this paper. Apart from this gratuitous insult to an anti-fascist, the authors can’t even get the name right (they call it “The Cochrane Group”), and they mistakenly assert that the Cochrane Collaboration only considers randomised control trials, the sort of basic factual error that would have been corrected with a few minutes’ actual research. Furthermore, contrary to the idea that the Cochrane Collaboration dictates policy, it does no such thing. All the Cochrane Collaboration does is collect volunteers to research a question of interest in medicine by digging up available studies and summarising their findings. It has no political, bureaucratic, or popular mandate. The only influence it has comes from the quality of the material it collects.

Many commentators have pointed out the idiocy of this paper, but I think it can be taken a step further. By singling out EBM as fascistic, by refusing to do basic research, and by mislabelling the legacy of a well-known anti-fascist, these authors are contributing to the disintegration of the word fascism and doing their level best to undermine health bureaucracies’ ability to administer effective medical care. And the worst of it is, this was published in a peer-reviewed journal. I think the board of directors ought to take a very good look at the contracts of their editorial department.