Clinical trials Complementary and alternative medicine Medicine Quackery Skepticism/critical thinking

What a fine belated blogiversary present: The return of the microfascists (and their micro brownshirts and microtruncheons)

Believe it or not, I missed my own blogiversary.

It’s true. It was two days ago. For some reason, as the date approached I got the idea that it was the 13th, when in fact this blog was born on December 11, 2004 on a dreary Saturday afternoon when, after reading the TIME Magazine story about how 2004 was supposedly the “year of the blog” and, given my long history on Usenet pontificating on various topics, on a whim, I decided that I’d dip my toe into this thing called the blogosphere.

Thus was Respectful Insolence™ born, and I’ve never looked back since.

Since then, this thing has grown beyond what I could have imagined. Oh, sure, it gets only around 1/8th the traffic of fellow ScienceBlogger Pharyngula, but among medical blogs, as hard as I’ve found it to believe, my traffic is pretty respectable and I seem almost in spite of myself to remain consistently in the top three to five ScienceBlogs (except when one or two or three of my fellow ScienceBloggers get Slashdotted or digged).

As my blogiversary approached, I wondered what (if anything) I should do to celebrate. Oh, sure, I could trot out EneMan. Heck, I even thought about taking PZ’s suggestion and coming up with an EneMan/Hitler Zombie crossover, but I just couldn’t do it, first because it would look as though I were bowing to the wishes of someone who was advocating feeding kittens to the Kraken, and neither of my sisters, both of whom have cats, would forgive me, and, second (and more importantly), there just wasn’t suitably warped material floating around that would lend itself to such a treatment. Someday, perhaps.

Fortunately, a reader turned me on to what could be the best belated blogiversary present of all, an article that is just crying out for some of that loving Respectful Insolence™ that is the very purpose of this blog. Do you remember an outrageously idiotic postmodernist attack on evidence-based medicine that I deconstructed back in August, entitled Deconstructing the evidence-based discourse in health sciences: Truth, power, and fascism? You don’t? Well, go read it now, or the rest of this article won’t make as much sense. You won’t regret it. It was one of my finest smackdowns of woo, if I do say so myself, and among the most satisfying, given how richly the target deserved it.

Are you back yet? Good. Because apparently microfascism is back. Well, not exactly, but rather apologism for the whole “microfascism” critique of evidence-based medicine (EBM). It turns out that the editor of the journal that originally published that travesty of an article back in August, the International Journal of Evidence-Based Health Care didn’t take too kindly at all to the criticisms that we microfascistic defenders of EBM leveled at it and in particular didn’t like Ben Goldacre’s deconstruction of its deconstruction and the comments it provoked. In fact, the journal did something I’ve never seen before. It published an impassioned defense of the article, and the authors of the article responded to at least one letter to the editor that had criticized the original article. It’s all thing of beauty on those occasions when you feel the need for administering some Respectful Insolence™ to a deserving recipient. Here’s the abstract:

Scientists, postmodernists or fascists?
Professor Alan Pearson RN MSc PhD FAAG FRCN
International Journal of Evidence-Based Healthcare
Volume 4 Issue 4 Page 385 – December 2006
Volume 4 Issue 4

The somewhat frenzied reaction to publication of a provocative, discursive paper titled ‘Deconstructing the evidence-based discourse in health sciences: truth, power and fascism’ by Holmes et al. in the International Journal of Evidence-Based Healthcare is both surprising and worrying. The paper is essentially a postmodernist critique of evidence-based healthcare. In the same issue of the journal in which the paper was published both the guest editorial and a response to the paper refute its claims. However, media coverage on the paper gave rise to numerous defensive responses that attacked the paper through claiming it represents ‘bad science’ or by disparaging the International Journal of Evidence-Based Healthcare, its Editor, its peer review processes or the organisation linked to the journal, the Joanna Briggs Institute. It is clear that those who mounted these attacks had no knowledge of the journal (or of the editorial and response refuting the claims made in the paper, published in the same issue) or its parent organisation; and none of them attempted to critique the paper in a scholarly fashion. This paper sets out to construct a scholarly argument to refute these claims and to consider why it is that those who support evidence-based healthcare and/or science chose to disparage a journal and an organisation that promotes and facilitates evidence-based approaches to healthcare – and the value of the Cochrane Collaboration – rather than developing a rigorous critique of the argument developed in the Holmes et al. paper. Although this response appears to be an attempt to silence dissenting views (and may, to some, suggest that the reference to microfascism in the paper in question may, indeed, have some validity) we conclude that the postmodernist critique of evidence-based healthcare embodied in the paper sets out criticisms that, though widespread in healthcare, can be challenged in a considered, scholarly way. The ill-informed, reactionary responses to it by the defenders of science make little contribution to the ongoing development of evidence to improve global health.

Heh. “Ill-informed”? Sadly, they’re not addressing me and appear not to have read my earlier critique. (Too bad; maybe I could have used a mention of Orac in a medical journal on my CV.) Either way, I would argue that the “microfascism” article was in actuality treated with at least as much respect as it deserved, if not more, and that includes my take on it. In any case, if the journal seems to be sticking to its guns in a most amusing fashion, leading me to agree with Dr. Goldacre. Not only is this the best early Christmas present ever for him, given his prominent mention in the article, but it’s a perfect belated blogiversary present for me. So, once more it appears that I must don my tight brown shirt (remember, according to Holmes et al., I’m a microfascist), my tiny jackboots, and put my truncheon on my belt, the better to go forth and crush the postmodernist foe, a red and white armband with “EBM” in black letters on my arm, a flag with a similar banner waving proudly above me, the better to inspire me to put my teeny-tiny microfascist boot on its throat and bash in its head, reveling in the blood spattering me as the real fascists did in the days of yore. (As in my previous article, I’ll leave it to the postmodernists to figure out whether I’m being metaphorical or not with this violent imagery.) In other words, Pearson (and Holmes et al.) are askin’ for another heapin’ helping of Respectful Insolence™.

To Pearson’s credit, his article at least is not quite as–shall we say?–target-rich an environment as the original Holmes et al. article. Indeed, its overall message can be summed up thusly: “Ben Goldacre and the commenters on his site are mean poopieheads. They’re unfair and didn’t address the substance of the article in a scholarly fashion.”(Stick out tongue here.) Never mind that Ben’s site is not a scholarly journal and has no obligation to write in a scholarly style. Unfortunately, I don’t have an institutional subscription to Int J Evid Based Healthcare (IJEBH), but fortunately the text of the article was posted to Ben Goldacre’s site. So let’s dig in. After a brief overview of postmodernism, Pearson concedes:

In critiquing the health sciences, serious postmodernist scholars acknowledge the possibilities for the advancement of population health inherent in current medical and healthcare research methodologies, conceding that the empirical sciences pursue practical questions and that this has led to the eradication of many previously overwhelming illnesses, diseases and symptoms. Although this flies in the face of radical postmodernists who are cynical about all forms of scientific endeavour, many postmodern scholars concede that the delivery of complex care to sick people – or the promotion of health in a population – must take heed of empirical evidence.

Well, duh. Nice of Pearson to admit that. But empirical evidence is anathema to postmodernists (who in fact mostly reject the very concept that there even is such a thing as “empirical” evidence), and the “critique” by Holmes et al. that provoked so much well-deserved criticism was so sloppily thought out and jargon-laden that it heartily deserved all the scorn heaped on it. In any case, the postmodernists to whom Pearson refers who accept the need for empirical evidence seem to be saying, “When it really, really matters, as in the case of your health and the health of your family, don’t listen to the hardcore postmodernists because, really, we all know they’re full of shit.” I will give Pearson credit for one other thing, too. He does list the critiques of Holmes et al. published as editorials fairly dispassionately. These critiques were very similar to mine and Dr. Goldacre’s, albeit written in only the finest Pearson- and IJEBH-approved scholarly prose rather than my Respectfully Insolent blogging style. Where it gets amusing is when Pearson goes on to whine about how those bloggers and commenters were so mean and nasty to Holmes et al. and to the IJEBH:

Ben Goldacre, writing in the British Guardian newspaper,9 summarises the argument of the authors as ‘evidence-based medicine rejects anything that isn’t a randomised control trial; the Cochrane Library is the chief architect of this project; and this constitutes fascism.’ He rejects the argument, though conceding that evidence-based medicine is seen by many as ‘soulless, and algorithmic’ he asserts that the argument proffered by the authors is ‘. . . a foolish misunderstanding. Evidence-based medicine is about using quantitative information, in concert with all other forms of knowledge, sensibly, in a clinical context. It does not denigrate other forms of knowledge.’ This Guardian column links to a web site named ‘bad science’ (Available at: – which filled up quickly with postings castigating the paper; not, though, with well argued critique of the paper, but largely with attacks on the journal. From the postings that appeared on August 20 2006, it was clear that the contributors had no knowledge of the JBI or the journal; that very few had attempted to locate the journal issue; and that this lack of detail did not weigh in their responses as information worth pursuing. As a result, none were aware that an editorial and a response to the paper – both refuting the conclusions drawn in the paper – were published alongside it. None of the contributors to the site revealed their names or contact addresses.

Boo-hoo! Mommy, make those mean anonymous bloggers stop!

My answer would be: So freakin’ what? The article was a mess and deserved every bit of criticism that it got. Once again I’d remind Pearson that Ben’s site is not a scholarly journal and thus has no obligation at all to use scholarly language . Besides, it’s a common practice in medical journals to publish editorials that critique the findings of major articles. That IJEBH published editorials critiquing the Holmes et al. article in the same issue it appeared, while admirable, does not inoculate the journal or its editors from criticism for having published such tripe in the first place. In addition, apparently few institutions have subscriptions to the journal, which means that most academics don’t easily have access to what’s in the rest of the journal. (Certainly I don’t, and I would appreciate it if anyone could send me a PDF of the article.) That is likely why the accompanying editorials got so little play. Moreover, the comments after Ben’s original article were more than just attacks on the journal. Indeed, several commenters acknowledged that there was the grain of a reasonable idea in the Holmes et al. paper before going straight to the heart of what was wrong with it, namely its willfully obscure jargon, which read like a parody of postmodernism and utterly buried under a mountain of pretentious jargon any valid points that could have been made.

Basically, Pearson doesn’t like all this criticism of the article and IJEBH and considers it all so dreadfully unfair and unsporting. Unfortunately, he neglects to address most of the substantive critiques that Ben’s article provoked and instead zeros in on the comments mentioning that the journal is not indexed in Medline and probably has a tiny impact factor, ignoring comments like Robert Carnegie’s pithy response:

I’d be prepared to believe that the word “fascist” has a technical meaning in the study of belief systems, perhaps relating to willingness or otherwise to import beliefs wholesale from other domains – such as the belief by major Web service providers that you should install their branded toolbar on your Web browser (you -may- get an opportunity to disagree) – if terror hadn’t been brought into it as well. Then you know they’re just being silly. “If evidence-based medicine rejects the beliefs of alternative medicine practitioners, the terrorists have won!”

Heh. I wish I’d thought of that one. The damned fascists make me pay my mortgage, too, or they’ll take away my house.

Or how about comment by Spinoza:

No ‘normative’ is not a posh way of saying normal. It means that a given phenomenon can be described only in relation to a set of norms. It has a valid use in intellectual discourse, although here it is being used in the usually sloppy po-mo way: we discover that (surprise, surprise) scientists being human beings are guided individually and collectively by values and make the illicit leap to the assumption that science is all about enforcing power. Now, some of these claims are not self-evidently stupid: science has been used to justify all kinds of nasty social practices and the best work in history and philosophy of science, and social studies of sciences can expose when this is the case. Indeed, this rather silly article trivialises a very serious set of issues about whether the Evidence-based framework is actually the best one in which to conduct medical research.

Indeed. The article was so ludicrously overblown that Pearson should not have been surprised at the reaction. But he was, and apparently continues to be:

The Holmes et al. paper is a polemic, grounded in the postmodernist critique of science and modernity, published in the official journal of the JBI. JBI is an international organisation that promotes and facilitates EBHC. The work of the Cochrane Collaboration – the focus of the critique by Holmes et al. – is strongly supported by JBI; indeed, JBI and its collaborating Centres conduct systematic reviews of the effects of interventions through Cochrane Review Groups; JBI actively encourages allied health professionals, nurses and medical practitioners to use the Cochrane Library; some JBI staff are office bearers in the Cochrane Qualitative Research Methods Group and/or members of Cochrane Review Groups; and JBI hosts the Cochrane Qualitative Research Methods Group Website. Thus, in labelling the proponents of Cochrane as ‘fascist’, the paper in question is criticising JBI as much as it does the Cochrane Collaboration.

You can practically feel the self-righteousness dripping from Pearson’s keyboard.

I’m glad that JBI actually supports the Cochrane Review groups and that there is cross-pollination between JBI and the Cochrane Collaboration, but color me unimpressed. Drivel is still drivel, even if you want to label your journal as “brave” and “able to take criticism” by publishing it. Personally, I have a bit of a problem with the whole concept of publishing “polemics” in academic medical journals, anyway. Biomedical journals are not the place for polemics. They’re the place for evidence and discussion of the evidence.


Sorry I forgot. My attitude makes me a “microfascist.” Time to twirl the ol’ truncheon again. Unfortunately, it’s an itty-bitty truncheon that can’t do any real physical harm because I’m a “microfascist.” Even more unfortunately, Pearson still doesn’t get it:

From the postmodernist perspective, it is appropriate to consider the underlying premises and purposes not only of Holmes et al. and their claim that the EBHS demonstrate the characteristics of microfascism; but also of the ‘scientists’ who think it is legitimate to respond to a paper such as this by regarding it as science (which it is not) and by supporting their disagreement of it by seeking to bring JBI and the International Journal of Evidence-Based Healthcare into disrepute.

By its very nature, an argument of the kind developed by Holmes et al. in ‘Deconstructing the evidence-based discourse in health sciences: truth, power and fascism’ is polemical in that its critique of science and the institutions and practices associated with it arises from suspicion and a deep sense of cynicism.4 The fact that such arguments are usually couched in language that incites a reaction is entirely in accord with the tradition of deconstruction.

Here’s a point for you, Mr. Pearson: No one was trying to bring IJEBH into “disrepute.” They were merely pointing out facts about the journal and complaining that they couldn’t find it on Medline or in their libraries. And Pearson has little justification in complaining about inflammatory language being directed at the article, when the authors of the article, by his own estimation, intentionally used language that “incites a reaction.” (At least Pearson admitted that the twaddle of Holmes et al was “not science.” I’ll give him credit for that, even though it should have been painfully obvious.) I would also point out that the real problem is the very concept of applying postmodernism to science. Science doesn’t work that way, nor is it a democracy. When Pearson states: “The notion that no one view, theory or understanding should be privileged over another (or that no discourse should be silenced) is a tenet of postmodernist critique and analysis,” it makes me think that, in postmodernist terms there is no reason why we shouldn’t give, for example, intelligent design creationism the same weight (“privilege”) as evolution in our consideration of the “evidence.” Or in medicine, it would seem, the postmodernist would give equal weight to quackery and view quackery and evidence-based medicine as merely “competing paradigms,” neither inherently more valid than the other. Moreover, the accusation that Dr. Goldacre’s article and the comments it provoked amount to an “attempt to silence dissenting views (and may, to some, suggest that the reference to microfascism in the paper in question may, indeed, have some validity)” is so utterly laughable that I find it hard to believe Pearson could have written it with a straight face. What power does a journalist and a bunch of commenters on a website (many of them anonymous) have to “silence” the IJEBH? None whatsoever! Here’s a hint for Mr. Pearson: Freedom of speech does not equal freedom from criticism. Pearson’s, I would note, is also the same lament of pseudoscientists since time immemorial when challenged to produce evidence to support their woo.

Damned that pesky scientific method!

Believe it or not, it really isn’t about science refusing to allow criticism accepted paradigms, as commenter by the ‘nym of Martin put it well:

Science is generally OK about attacks on ‘sacred cows’; without critical thinking science wouldn’t have moved on since Galileo. But science does require the attack to be based on sound evidence. I could refute all of Stephen Hawking’s work (I have at least read his book), but without any proof I’d be (rightly) ignored.

Indeed. And I could refute all of, say Judah Folkman’s work, but if I didn’t provide compelling experimental evidence to support my refutation, no one would (or should) take me seriously.

I’m done with Pearson now. Besides, he’s not nearly as amusing as the real deal (Holmes et al), which is why I’ve saved the best for last. In a letter to the editor, Tom Jefferson, MD, accused Holmes et al of “conducting an epistemiological lynching “of the Cochran Collaboration and its work. Holmes et al didn’t like this remark at all:

Remarkably, you raise the racist, hateful spectre of lynching. To be clear: we, the authors, are far from an angry lynch mob, real or illusionary. Lynching, in the strongest sense of this term, was a racist murderous practise of the Southern United States until the mid-twentieth century; it sought black submission through terror tactics; and it was often ‘legitimated’ though perverse appeals to patriotism and divine will. Indeed, the lynching of blacks was often tolerated or even unofficially sanctioned precisely because of an ideological refusal to engage in critical political debate – an unwillingness to interrogate those rigid political hierarchies by which white supremacy was the prevailing ‘regime of truth’.

Does irony get any richer? These guys were so anxious to label evidence-based medicine a “fascist” construct that crushes competing paradigms and thought nothing of invoking the names of Hitler, Mussolini, and, that apparent enemy of enemies, George Bush in their attack, but then get totally bent out of shape when the metaphorical use of the term “lynching” is directed at them! In fact, they’re so bent out of shape that they even retreat from postmodernistic relativism and lay out a concrete definition of the word “lynching” and the associated history behind it that makes the term so offensive to them. Hilarious! But they go even further in that they link lynching to an unwillingness to “interrogate those rigid political hierarchies”–like EBM! Apparently Holmes et al. can dish it out, but they can’t take it. Even more amusingly, they then go on to liken the Cochrane Collaboration to the “regime of truth” in the past of white supremacy:

If nothing else, the ‘meat’ of our paper is not to reduplicate but to expose rigid political hierarchies and to engage in critical political debate. We argued that the evidence-based movement (EBM) is part of a wider political regime of truth; that it relies on potentially dangerous hierarchies, such as the Cochrane taxonomy; and that it ideologically refuses to critique the deeper terms of its own ‘legitimacy’.

That’s right; we fans of EBM are just tools and part of a wider fascistic “regime of truth.” You know, the same one that led to fascism and lynchings. Can these guys see just how ridiculous they sound, what a load of bullshit they’re laying down, and how hypocritical they’re being by going so ballistic over the metaphorical use of the term “lynching” and yet apparently whining that the strongly negative reaction to their use of the term “fascism” and invocation of Mussolini and Hitler when discussing EBM is unjustified?

I can’t take it anymore. (Actually, I’m laughing too hard and have to stop soon, lest I hurt myself.) Even when responding to criticisms, Holmes et al can’t drop the idiotic postmodernistic blather. OK, that’s not entirely true. I can take just a little more, just because this last bit is so outrageously over the top and funny that I can’t help it:

It would be disingenuous to dismiss our argument as unscholarly just because it is controversial and disrupts the status quo. To repeat, we do not wish to do away with ‘evidence’, to subvert one hierarchy only to replace it with another, more ‘utopian’, one. The purpose of our critique was to spark epistemological and political debate over the implicit paradigms that impose a dangerously narrow and rigid system of ‘truth’, and impose it universally. To overlook the effects of research paradigms and their associated epistemologies is a major flaw in the Cochrane taxonomy. Instead, we argue that researchers ought to encourage diverse and pluralistic paradigms and to eschew the rhetoric of the ‘average patient’, which is potentially totalising.

Help, help! I’m being repressed! Again. Of course, now that Holmes et al. stirred up the very “debate” that they profess to have wanted, they don’t seem to be too happy about it.

Once again Holmes et al. tell us they don’t wish to do away with “evidence”; they just want “pluralism,” which, in the postmodernist world, would (I guess) mean that there would be no epistemological basis to reject, say, homeopathy as ineffective, because, when you come right down to it, all those glowing anecdotes would count as “evidence” for homeopathy just as much as the the evidence of RCTs that show that homeopathy doesn’t work any better than placebo and all that nasty, fascistic, intolerant chemistry, pharmacology, and biology that says that homeopathy is bunk count as evidence against it. Even more maddeningly, they continue to appeal to other ways of knowing but conveniently once again fail to mention a single such “other way of knowing” that could be compared and contrasted with the existing paradigm of EBM. That’s just intellectually sloppy and lazy. If they’re so unhappy with the accepted “way of knowing,” couldn’t they at least discuss another?

Sorry, guys, but if that’s your epistemology, I’ll stick with my outrageously exclusionary epistemology of EBM. As I’ve pointed out before, there are legitimate critiques of an over-reliance on pure EBM, which has many shortcomings having to do with the impossibility of doing RCTs about every question that we need to answer; its tendency to devolve into cookbook algorithms if not used wisely; and the perception that it lacks the “human” side of medicine. Too bad Holmes et al once again fail to make any of those critiques in a coherent fashion, or even at all in the case of most of them. Instead, they respond to criticism of their silly, intentionally inflammatory, postmodernist jargon-filled polemic with silly defensive, intentionally inflammatory postmodernist jargon-filled polemic, all while Alan Pearson whines that all the bloggers who quite justifiably took them to task for their silly, intentionally inflammatory, postmodernist jargon-filled polemic are all a bunch of meanies for justifiably pointing out bullshit when they see it.

By Orac

Orac is the nom de blog of a humble surgeon/scientist who has an ego just big enough to delude himself that someone, somewhere might actually give a rodent's posterior about his copious verbal meanderings, but just barely small enough to admit to himself that few probably will. That surgeon is otherwise known as David Gorski.

That this particular surgeon has chosen his nom de blog based on a rather cranky and arrogant computer shaped like a clear box of blinking lights that he originally encountered when he became a fan of a 35 year old British SF television show whose special effects were renowned for their BBC/Doctor Who-style low budget look, but whose stories nonetheless resulted in some of the best, most innovative science fiction ever televised, should tell you nearly all that you need to know about Orac. (That, and the length of the preceding sentence.)

DISCLAIMER:: The various written meanderings here are the opinions of Orac and Orac alone, written on his own time. They should never be construed as representing the opinions of any other person or entity, especially Orac's cancer center, department of surgery, medical school, or university. Also note that Orac is nonpartisan; he is more than willing to criticize the statements of anyone, regardless of of political leanings, if that anyone advocates pseudoscience or quackery. Finally, medical commentary is not to be construed in any way as medical advice.

To contact Orac: [email protected]

Comments are closed.


Subscribe now to keep reading and get access to the full archive.

Continue reading