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 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.