Anticipation and Medicine: A Critical Analysis of the Science, Practice, and Perversion of Evidence Based Healthcare

Book Title: Anticipation and Medicine: A Critical Analysis of the Science, Practice, and Perversion of Evidence Based Healthcare

Book Author: Owen Dempsey

Publication Information: New York, Routledge, 2019, 140 pp, $45.95, paperback

Opening this book is a trip back in time. It brings the reader to the previous century and the halcyon days of Marxist philosophy and Freudian psychology when these schools of thought dominated not only the academy, but nearly every corner of thought and society. In the introduction, the author explicitly states that this volume’s critique of evidence-based medicine is through the lens of Karl Marx’s analysis of capitalism and Jacques Lacan’s psychoanalytical theory. While the author’s integrity in laying these cards on the table is appreciated, it was hardly necessary: in the two pages prior to this acknowledgment and throughout the remainder of the book, the buzzwords and expressions of the narrative are quite recognizable to anyone familiar with the writings of these historical figures.

It is easy to understand the author’s aversion to evidence-based medicine (EBM). Empirical data is not kind to the pillars of his approach, with the disastrous experiments in Marxism (eg, the former Soviet Union and the intriguing crossover experiment between Marxism and capitalism in China), and the near absolute lack of evidence of benefit from Freudian-style psychoanalysis.1 While this worldview is likely contrary to that of many of those seeking to practice evidence-based medicine, it is worthwhile to hear the objections raised and view the topic from a different perspective… one that some of our patients likely hold.

The focus of the book is on EBM as applied to anticipatory guidance and preventative health care, that the author believes is “antidemocratic… exploits desire, coerces compliance, causes distress, bankrupts, and destroys health and care for many” (p 17). The book’s organization is logical, beginning with clearly explained definitions of terms, a presentation of the author’s thesis, then a fleshing out of the specific points of the thesis using the British breast cancer screening practices to illustrate the points.

The author describes the current practice of EBM as the “takeover of objective empiricism by a humanist and radical empiricism, an elitist subjective version of what ‘should’ guide…practice” (Dr Dempsey’s emphases, p 3). He objects that “neoliberalpragmatist ideology decides practice of EBM and prohibits any limits on new forms of anticipatory care or the harm this causes” (p 5). Phrased differently, much of EBM is the interpretation of data and the application of this interpretation to patient care by experts—expert opinion masquerading as objective facts. This is a valid criticism of the current practice of medicine—how often we encounter guidelines that list a strong recommendation for some action based upon a very low level of evidence! The Strength of Recommendation Taxonomy2 is an approach developed by scholars of our discipline in an attempt to overcome this.

Another objection to the current practice of EBM is that “Population-based (care)… provides relief from the stresses inherent in interpersonal caregiving” (p 6), and “anticipatory care removes love from care” (p 94). With busy practices and current reimbursement schemes, it is easy to default to clicking the pop-up order set rather than to engage the patient in a discussion that will permit truly informed shared decision making regarding which screening strategies make the most sense for the individual. As family physicians who know our patients, their context, and their values, we should be leaders in rendering this objection moot.

Perhaps the most important objection is the “Anticipatory Healthcare Paradox”—in seeking to promote health, harm is inflicted. All health care interventions—medical, surgical, herbal—always have the capacity to do harm, and preventative care is no exception. Yet there is a strong tendency to minimize the collateral harms that it inflicts in our phrasing of the benefit vs risk. As a physician, the discomfort of bowel prep and the possibility of perforation in a low-risk patient are worth the potential benefit of early detection of (likely absent) colon cancer. Not all our patients would agree.

The author makes a distinction between absolute (highest attainable) vs qualified (personally good enough) health, future vs present suffering, and population vs individual health. All are important considerations in the application of health care, and are value judgments for which there are no objective EBM answers. And that is, perhaps, the bottom line of this book.

Dempsey’s approach to the perils of the EBM is novel, and makes for an interesting read. The majority of the points he makes are valid, and are the same ones many others make, though they may start from a different place philosophically.