The Science, Praxis and Perversion of Evidence Based Healthcare: anticipation and medicine

Abstract

In this thesis I am addressing the anticipatory care paradox. This is the way in which anticipatory diagnostic interventions, such as cancer screening, applied to asymptomatic populations in order to predict and prevent future illness, are being implemented in the name of improving health but are, in fact, causing increasing harm to health itself and to the capacity to care and respond to suffering with love. The overall argument that I am presenting is that whilst both the offer and the implementation of such interventions are warranted on the basis of an apparently objective and democratic philosophy of Evidence Based Medicine (EBM), instead these kinds of interventions are, on the whole, subjective, mis-leading, anti-democratic and oppressive. I show that this is because such interventions: a) incite anxiety and fear that exploit desire; b) are fetishised both as commodities and as object causes of desire; c) depersonalise care-providers and ‘patients’ making it harder to provide or access interpersonal care with love; and d) demand excessive implementation for implementations sake, and may even lead to a perversion of care that harms for harm’s sake. I do this by using a Lacanian psychoanalytic perspective on subjectivity - the formation of identities as dependent on an underlying insufficiency of self-consciousness and vulnerable to desire and anticipation. I show how subjectivities of both care-providers and ‘patients’ are formed in relation to apparently authoritative ‘offers’ of anticipatory care and treatments that determine what can be meant by the aim of such care through signifiers such as health, and doing the good. And, I show how these meanings are produced by ways-of-knowing and language in discourse underpinned, not by EBM, but by the ideologies of a) neoliberal capitalist political economy and b) the scientific philosophy of pragmatism. I use Lacan’s structure of discourse to take advantage of the strong analogy between the structure of the capitalist economy at a social level as analysed by Marx, and the stucture of the psyche of the subject of capitalism, at an individual level, as analysed by Lacan. I have identified a normative effective truth, used to justify anticipatory medical care, that is misleading, anti-democratic and oppressive, and that dominates health care beliefs and praxis in this important and expanding field. I have shown that the justification for this form of care is sustained by EBM’s scientific philosophy that: a) disavows the problem of the threshold between the normal and the pathological; and b) psychologises the minds of individuals, as if they are totally responsible for their beliefs, as if these are independent of social reality and processes.

Date of Award	31 Dec 2019
Original language	English
Awarding Institution	The University of Manchester
Supervisor	Julian Williams (Supervisor) & Ian Parker (Supervisor)