A Post-Structuralist Viewpoint on Evidence-Based Medicine
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A post-structuralist viewpoint on evidence-based medicine by Brian Walsh Submitted for the degree of Doctor of Philosophy University of Otago 2012 ii Abstract BACKGROUND: Evidence-based medicine has made a remarkable contribution by organizing and processing overwhelming amounts of information. Furthermore, some tests and treatments have been shown by EBM to be inappropriate. However, evidence-based medicine (EBM) has been criticised on four fronts. 1. It is reductive. 2. It is undertheorised. 3. It lacks RCT evidence for the method as a whole. 4. It was, at first, totalising. AIM: This work aims to provide a viewpoint on EBM from the writings of three twentieth century French philosophers, often described as “post-structuralist”. METHOD: Employing discourse analysis, I use A Thousand Plateaus and Anti- Oedipus, written by Gilles Deleuze and Felix Guattari, to develop a post-structuralist viewpoint on EBM. In Part Two I use The Birth of the Clinic and Power/Knowledge by Michel Foucault to provide a slightly different post-structuralist viewpoint on EBM. RESULTS: The Deleuzian teaching on smooth space (versus striated space) and nomadic science (versus State science) celebrates a less structured approach to medicine than that provided by EBM. This latter is viewed as part of a State science discourse in which knowledge and power are combined in a regime of truth. According to EBM, although medicine has a number of disciplines contributing to it, epidemiology provides the best evidence. But this work draws on the distinction between State science and nomadic science to feature the struggle in which the voices of disciplines other than epidemiology are quietened with regard to what constitutes “evidence”. Post-structuralist philosophers view all this as a partly successful striation of smooth space by a complex of powerful institutions. EBM only partly fills disease's numerous conceptual spaces. An instrument of power, the medical gaze is complex, but anything which is excluded from this beam is iii thereby excluded from medical research and knowledge. The gaze arguably does not engage with the post-structuralist subject, and makes a poor job of dealing with those aspects of medicine in which biology interacts with culture. Although EBM leaders have published a paper on their philosophy in 2009, I consider that they have rushed over some very complex issues. These include representational thinking, with its shaky matching of the signifier with the ephemeral signified, massaging the trial results for consumption by clinical doctors, limitations of probabilistic thinking imposed from outside the profession, the complexities of subjectivation which is rife in EBM, the ethics of compliance with EBM as distinct from the ethics of authentic practice, and the effects of the signifying regime of signs on propositions passing through it. Although in 2008 EBM leaders gave detailed advice about applying the results of research on groups of experimental subjects to the next patient, the gap has been reduced but not canceled. This work provides a Deleuzian analysis of the problem, but not a solution. iv Acknowledgements Professor J. Coveney of Flinders University gave me the idea of developing a viewpoint on EBM from Foucault. Professor Grant Gillett and Professor Dave Holmes have extensively advised me and believed that I could think. Dr. Peter Beecroft has advised me on presentation. Most staff , including the secretary, at the Bioethics Centre at Otago University have contributed. In particular, Flora Huang gave me the main idea for the chapter on what EBM has contributed to philosophy. At the Department of Philosophy at the University of Auckland several people have taught me philosophy. In particular, Dr. S. Franchi and Dr. R. Irwin were among the people who taught me continental philosophy, and Professor R. Nola taught me Philosophy of Science. At the Department of General Practice and Primary Health Care at the University of Auckland, Professors S. Buetow and T. Kenealy have supported me. Professor B. Arroll put me in touch with Professors Gordon Guyatt and Ben Djulbegovic, who have contributed. The remote library service at Otago University has sent many books. I have been taught to search the internet by a number of people including Dr. J. Kennelly, Bevan Walsh, Mark Stephens and Vivian McPhail. Bevan Walsh provided extensive support with office equipment and word processing. Vivian McPhail has assisted me with formatting the document. My family and friends supported me. v Table of Contents Introduction...............................................................................................................1 Chapter 1: Research Problem...................................................................................3 1. 1. Statement of the problem.............................................................................3 1. 2. Literature review .........................................................................................4 1. 3. Research objective.....................................................................................16 1. 4. Research questions.....................................................................................16 1. 5. Previous research and how this work relates to it.....................................17 1. 6. Epistemic stance.........................................................................................19 Summary of chapter 1.........................................................................................31 Chapter 2: Introduction to EBM then a contrasting approach ...............................33 2. 1. EBM...........................................................................................................33 2. 2. Casuistic-Based Medicine (CBM)--an approach alternative to EBM ......39 Summary of chapter 2 ........................................................................................40 PART 1: DELEUZE AND GUATTARI.....................................................................41 Chapter 3: The philosophy of Deleuze and Guattari...............................................41 3. 1. First introduction........................................................................................41 3. 2. Structuralism..............................................................................................42 3. 3. The philosophy of Deleuze and Guattari...................................................50 Summary of chapter 3. .......................................................................................85 Chapter 4: A view of EBM through the Deleuzian teaching on desire, difference, immanence, Oedipus and capitalism.......................................................................87 4. 1. Desire is more fundamental than the rationality of EBM ..........................87 4. 2. Economics...................................................................................................89 4. 3. The positivity of desire...............................................................................89 4 4. What about philosophy? ............................................................................90 4. 5. Difference ..................................................................................................91 4. 6. Oedipus .....................................................................................................92 4. 7. The "lack of philosophy and evidence" viewed as part of a war ...............92 4. 8 . Immanence.................................................................................................93 4. 9. Capitalism..................................................................................................95 vi Summary of Chapter 4........................................................................................98 Chapter 5: A view of EBM through the Deleuzian depiction of the postulates of linguistics and of the signifying regime of signs.....................................................99 5. 1. The postulates of linguistics........................................................................99 5. 2. The signifying regime of signs.................................................................100 Summary of chapter 5.......................................................................................111 Chapter 6: A view of EBM through the Deleuzian metaphors of the rhizome, smooth space and striated space, segmentarity, and nomadic science and State science ...................................................................................................................113 6. 1. The rhizome..............................................................................................113 6. 2. Smooth and striated spaces.......................................................................118 6. 3. Segmentarity.............................................................................................119 6. 4. State science and nomadic science..........................................................121 Summary of chapter 6.......................................................................................137 PART 2: FOUCAULT..............................................................................................139 Chapter 7: Foucault and the spatialisation of disease...........................................139 7. 1. The body: The space of anatomy..............................................................140 7. 2. The configuration of disease: The space of pathology