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Complessità, Non-linearità e Psiche
Satellite Navigation Systems, Evidence-Based Medicine, Religions And Totalitarianism
Franca Pezzoni (1) , Giacinto Buscaglia (2)
N.B. This article is not evidence-based
When we run over libraries, persuaded of these principles, what havoc must we make? If we take in hand any volume; of divinity or school metaphysics, for instance; let us ask, Does it contain any abstract reasoning concerning quantity or number? No. Does it contain any experimental reasoning concerning matter of fact and existence? No. Commit it then to the flames: for it can contain nothing but sophistry and illusion.
Hume, An Enquiry Concerning Human Understanding.
What strikes us about this quotation from Hume, a well-known exponent of enlightened science and tolerance, is that the reader is seen as visiting the library in order to select, eliminate and destroy, through the application of a scientific criterion, rather than to understand.
This approach is of particular relevance to us, in that, as psychiatrists who work in public services, we are constantly called upon to deal with complex issues that may be difficult to quantify; and even if they could be quantified, one wonders whether this quantification would make any sense.
What we are referring to here is the vast number of everyday experiences concerning the human relationship with patients and their families, thanks to which people often feel better. It is an accumulation of practices and of history that is difficult to express or to pass on; moreover, it makes no sense to discard it merely because it cannot be made to run the gauntlet or adapted to the Procrustes bed of the publication criteria of the internationally accredited journals. Then again, one need only listen to the comments of patients and their relatives in order to discover that what they seek and appreciate most are factors linked to the human relationship, such as commitment, accessibility and continuity of the relationship, rather than the application of specific techniques (Buscaglia et al., 2004).
In this perspective, it may be claimed that psychiatrys need to strengthen its scientific status has prompted an increasingly marked shift towards a model which has evidence-based medicine (EBM) as its principal point of reference. Beyond the fashions that periodically come to the fore only to be replaced by others, and in spite of the risk of being accused of obscurantism, sentimentalism and scant scientific spirit, we feel that it is worth reflecting attentively on the value of EBM and on the effects that it has on clinical practice and the planning of psychiatric services.
The disagreeable sensation of seeing a wealth of clinical experience undervalued, if not burnt (to return to Humes exhortation), reminds us of a curious episode concerning the use of a satellite navigation system. Having set the instrument to guide us to our destination, we noticed that it was stubbornly leading us in a completely different direction from that indicated by the maps, road signs and our own sense of orientation. Regardless of the reason for this error, it became clear that, if we had deprived ourselves of the other sources of information from the outset and relied exclusively on this instrument, we would have been unable to correct the route, or even to realise that we were going in the wrong direction.
Another misadventure, this time concerning two Swedish tourists, was recently reported in the newspapers. In the tourist information office in Carpi, they asked where they could find the famous Faraglioni (Needles). Having set their satellite navigation system to Carpi instead of Capri, and ignoring all information provided by their senses, they had found themselves in the middle of the Padana Plain, under a torrid August sun, imagining that they were on a southern Italian island. Some time before that, in Gillingham in Dorset, four members of a theatre company had to be rescued after their navigation system had led them to drive their van into a river in spate.
Obviously, we are referring to the satellite navigator as a metaphor and we certainly do not wish to deny its utility. Likewise, we have no intention of discussing the specific nature of the mistakes that were made. In both of the above cases, reliance on a single instrument, however sophisticated it may be, and the exclusion of other means of orientation, gave rise to gross, indeed grotesque, errors.
The risk here is not only that we may deprive ourselves of important sources of information, but also, and especially, that we may take the wrong direction because we underestimate the instruments of correction. Admittedly, EBM does not claim that these non-evidence-based sources of knowledge are useless; rather, it establishes a hierarchy of values in which priority is given to that which is demonstrated according to its own criteria.
To return to our example of the satellite navigation system, it seems that different weights should be attributed to the various sources of information; the following sources are listed in increasing order of weight:
- intuition, sense of direction, perception of the landscape (rivers, position of mountains, etc), geographic notions learnt at school;
- dialogue and discussion among the travellers, who compare and share their impressions and notions;
- milestones and road signs, the traditional method already in use in Roman and mediaeval times;
- paper maps, which may not be up to date;
- directions provided by the satellite navigation system, which is equipped with electronic roadmaps.
All of these instruments are in themselves reasonable and rational; there is nothing esoteric or magic about them. To consider them obsolete, in a world that is reduced to the bare minimum, means leaving ourselves only one direction to follow, whether it be right or wrong.
To persist with our metaphor, it should be underlined that the objectives of scientific research are usually more complex than finding a fixed point on a map, the existence of which is incontrovertible. In psychiatry, this notion is even more evident, and the risk is not only that of going in the wrong direction, but also of reaching an objective which, if not non-existent, is at least misleading.
If, therefore, in our clinical practice, the satellite navigator corresponds to EBM guidelines and methods, the other sources of information can be likened to classical psychiatric literature, current clinical practice, discussion with colleagues and patients, common sense and all those data provided by the cultural, emotive and human components of the context. However, we have the clear impression that this hierarchical arrangement of the sources of information is, in reality, a progressive shedding of the world of life, which is regarded as a source of distortion, disturbance and confusion that should be eliminated.
Some authors have analysed fascism on this basis (Holmes et al., 2006). We feel that the term totalitarianism (Arendt, 1951) is more appropriate. Indeed, if this criterion of reduction, of stripping away, is adopted in order to reach a definition of truth, how can it fail to evoke the dehumanising mechanisms implemented in total institutions and in the death camps ?
All of this is no mere theoretical exercise; it also has serious practical repercussions, which are plain to see and which reinforce the totalising component of the model. We are referring to the strong influence on the publication criteria of the internationally accredited journals of all that is not evidence-based (such as teamwork, fieldwork, home visits and contact with the personal setting), and to the impact that EBM has on the criteria of health service financing. Indeed, clinical studies have steadily been reduced in favour of papers with an epidemiological slant. Another easily verifiable observation is that those who are involved in EBM often do no clinical work, or do it only in part. This has led to a lamentable split between clinical activity and research, with reciprocal accusations being exchanged between clinicians and epidemiologists. The clinicians claim that the epidemiologists do research that is reductive and, at bottom, useless, while the epidemiologists accuse the clinicians of being culturally backward and fraught with prejudice.
The hierarchy of information, which attributes greater weight to evidence than to experience, in practice embodies, as in the case of the satellite navigator, the idea that there exists a single, objective truth; if this truth cannot be fully grasped, it is only because of the imperfection of the instrument, which must therefore be continually refined.
We wonder what it is that prompts the EBM model to neglect raw data by which we mean life in all its awesome complexity in favour of a somewhat naïve faith in the existence of an objective reality that cannot be fully grasped only because of the limitations of the available scientific instruments, and which upholds the assertion that, if something is not currently measurable, it surely will be in the future. It is a sort of methodological obsession which aims to eliminate the human component. Taken to its logical conclusion, it would lead to the design of studies that were not double-, but treble- or quadruple-blind, in an escalation aimed at separating not only the researcher from the patient, but also the research designer from the researcher who implements it.
If there existed a world totally dominated by EBM, there would be no room for scientific evolution, which, as we all know, often stems from chance observations, cross-pollination among different disciplines, trial and error, and the serendipity factor. To do away with all of that and, especially, to intimidate and denigrate clinical intuition would result in a lamentable impoverishment of opportunity and knowledge.
The fans of this model end up touching on fanaticism; they profess to be the only custodians and propagators of true scientific method. Thus, they become veritable missionaries, who spread the word and aspire to purification through the elimination of all those components that are not derived from a single criterion.
This observation appears to be particularly apt, in that the zeal with which this model is often presented displays a religious component if by religion we mean a set of ethical, moral and practical convictions that constitute a system of faith and worship, that is to say, a religious ethic (Merton, 1967). The critical spirit can be directed against EBM itself if we try to understand the origins of sectarian attitudes. In this regard, it is helpful to turn to Weber and his study of the Protestant ethic, particularly that of Calvinism and Puritanism. We will therefore utilise his definitions and various quotations regarding this ethic.
It is well known that Calvinism is based on the concept of predestination, as expressed in the articles of the 1647 Westminster Confession. Because of his fall into a state of sin, man has totally lost his capacity to want anything that is spiritually good or conducive to health; thus, completely turned away from good and spiritually dead as a result of his state of sin, he is incapable of conversion, or even simply of preparing for conversion. God, in order to manifest his majesty, has predestined some men to eternal life and others to eternal damnation. Those who are chosen for salvation have been elected by God in accordance with His eternal and immutable design, and not because of their faith or good works, or anything else that may derive from the creatures themselves. It pleased God, in accordance with His inscrutable will, to neglect the rest of the human race, to condemn these unfortunates to disgrace and ire on account of their sins, in order to glorify His divine justice. Every creature is separated from God by an insurmountable abyss and deserves only eternal damnation. To admit that human guilt or merit might contribute to determining salvation is tantamount to saying that man can influence the absolutely free decisions of God, who has preordained every atom of the cosmos.
In its inhuman pathos, this doctrine gave rise to an extraordinary interior solitude on the part of the individual; each man was set to tread his own path alone and no one could help him: not the religious community (as it does in Catholicism), not the sacraments, not even God himself.
Puritanism regarded all means based on tradition, on rites, on sacred music and art and on prayer as magic. It even repudiated any trace of religious ceremony on tombs, and the dear departed were buried without music or song, so as not to arouse superstition in any form. The fact that everything human is absolutely remote from God and absolutely lacking in value imposed the total devaluation of senses and sentiments, since they were useless in terms of salvation and were sources of illusion and superstition.
The doctrine of election, even when it lost its efficiency as dogma, left evident traces on conduct and on the conception of life. It appears, for instance, in the warning not to place ones trust in the friendship or nature of men; one is advised to maintain a deep distrust even of the closest friend, and urged not to confide in anyone. God must be the only confidant. A preacher says that when we go forth among people in our daily lives, we must be aware that we are venturing into a wild forest full of danger. In Bunyans Pilgrims Progress, the protagonists realisation that he is living in the city of perdition drives him to abandon his wife and children in order to free himself from all human bonds; blocking his ears against the pleas of his family, he cries Life! Eternal life!. Any relationship that is purely sentimental, that is to say, not conditioned rationally, between one person and another, easily falls under the suspicion of being a deification of the creature.
The Calvinist is uplifted by the thought that, in the organisation of the world, and therefore also in the social order, God wants what objectively corresponds most to His greater glory, not the creature as an end in itself, but rather the order of the creatures subordinated to His will. All action is thus directed towards the rationalisation of the world (see the environmental consequences).
The only way the individual could survive within this doctrine was to obtain certitudo salutis, the certainty of salvation, which came from the awareness of fulfilling his own duty. It was important to pick out certain signs of belonging to the elite; credence could not be given to simple personal testimony, since sentiments and states of mind, however sublime they may appear, are fallacious. Faith must be experienced in its objective effects in order to serve as a secure basis for certitudo salutis; it must be fides efficax. Righteousness is not a gradual accumulation of single meritorious actions, as it is in Catholicism, but a systematic self-analysis aimed at ascertaining whether one is saved or damned. Membership of the elite is verified through a constantly vigilant search for its signs, in oneself and in others signs that are, as far as possible, objective and quantifiable. Success is indirect proof of salvation; then again, we can speak of success only if the individual sets himself objectives, strives to achieve them according to methodical and rational procedures and guidelines, and then evaluates in quantitative terms, if possible monetary terms, whether or not he has reached them.
In Catholicism, the grace of the Church was on hand to make up for the deficiency of the individual. By contrast, the God of Calvinism demanded a sanctity of works that was elevated to the status of a system. Ethical practice (and not only) was transformed into a methodical and consequent conduct of life. As the efficiency of grace could be demonstrated only in a fundamental transformation of the meaning of life, at each single hour and in each single action, the life of the saint was directed toward a single end and, in all its aspects, was rationalised and dominated by an exclusive point of view. The constant control of the self enabled the individual to master his affections and passions and to suppress the unprincipled and impulsive enjoyment of life. The concept of idolatry was extended to all of the joys of the senses, unless they were justified on hygienic reasons. The chosen ones were sure of their own salvation. They therefore felt no indulgent inclination to help those who were damned, or presumed to be so; rather, they looked upon them with hatred and contempt, as upon enemies of God. Bewährung, meaning the experience and proof of salvation, was constantly verified by means of religious diaries in which any progress made was reported in the form of tables and statistics. Unable to reconcile himself with God, man had to maintain his awareness of his own condition of abandonment and dereliction, not with the impossible aim of earning salvation, but rather to reflect the human condition in his suffering. Entertainment, affections and artistic activities were seen as distractions and as a culpable evasion of this single truth (Williams, 1972). Hence the distrust for everything that is easy, pleasant, comfortable, habitual, spontaneous, natural.
Within the doctrine of predestination lies the conviction that an immutable law exists: the law is there and must be discovered. Predestination is a fact, in the meaning that this word has in the natural sciences; there is faith in the validity of a single basic postulate.
Puritanism shares with mediaeval Catholicism the idea that this world is evil. However, while the latter advocates withdrawing from it, the former demands that temptation be overcome through incessant industriousness, a sort of lay asceticism, within the world itself. With desperate insistence, the Puritan asks himself the question: how can I know whether I am among the elite? The burden of salvation is shifted from the Church to the individual and this crushing responsibility can only be alleviated by the justification obtained through legitimate occupations that yield proven and provable results (Merton, 1967). Agreement with the world is intolerable. The world must be conquered and controlled, and this constraint is exerted on all aspects of life. As Weber says, a somewhat comfortable form of religion was substituted by a new, totalising form that penetrated into all spheres of life. What the reformers condemned was not an excess of religious dominion over life, but a deficit. The whole of life had to be geared to a system and to a method, and the objectives to achieve were bereft of any eudemonistic or merely hedonistic aspect. Everything must be scrutinised rationally, reason takes on a compelling authority, and science becomes an imperative duty. Nothing must be left as it is, or believed before being subjected to examination.
According to this view, tradition, authority, culture and history should be looked upon with suspicion, since they are conducive to deception rather than to truth; truth is to be found at the origin, before sacred texts were subjected to interpretations and distortions. On the basis of the principle of scripture alone, the Bible is taken as the sole reference and subsequent accretions are stripped away. The idea of a single criterion as the source of knowledge is taken up at the scientific level and leads to the expulsion of those areas of knowledge, which in the Renaissance period were grouped under the heading of studia humanitatis, that do not fit into the new idea of exact science.
Symbols, customs, rites and images are regarded as superstitions that must be purged. Sacred images and holy places are considered to be pagan, and systematic destruction ensues (Sheldrake, 1990). The tombs of saints are violated, relics thrown away, stained-glass windows shattered, and frescoes scraped off or whitewashed in a sort of chromophobia (Pastoureau, 2008). The spiritual world is confined within man, while the material world becomes neutral and indifferent, governed by impersonal laws and amenable to any form of manipulation. Anything which evokes an aesthetic or emotive effect, or has a sacred value, even in the simplest sense that it is venerated and conserved for reasons of affection and tradition, must be eliminated because it is superstition, magic, idolatry. Supervision must be permanent and relentless, because the iconoclasts realise that the physical elimination of simulacra is not enough; these phenomena constantly re-emerge from within. Calvin considered this tendency to be a fundamental defect: As water overflows from any full vessel, so a huge array of gods are released from the human mind.
Without restraint, Nature must be probed through extremely active methods. In the words of Francis Bacon, who used metaphors taken from the techniques adopted during the interrogation of alleged witches, Nature manifests itself better under torture and through the use of (mechanical) artifices than when it is left to itself. It must be subjugated, enslaved and imprisoned. It must be forced out of its natural state, squeezed and moulded (Sheldrake, 1990).
This stripping away of the sacred and of the spirit extends to all places, not only natural but also human (historical, religious, urban), and turns them into de facto non-places. As noted by Augé, the places in our lives are bound up with identity, relationships and history; they possess meaning for the individual, in that they constitute the centre of shared relationships and have stability and continuity. They are characterised by intersecting pathways where people meet, get together and speak; they have centres that hold memories and monuments of the past, which represent continuity from one generation to the next and which are recognized as still living in the present. The individual feels that they existed before him and will continue to exist after him. Modernity, however, rather than integrating what existed previously, destroys it; it creates spaces that are disconnected from identity, relationships and history, where the individual finds himself alone in a particular and modern form of solitude. Both the place and the subject are emptied of all content and meaning in a systematic and generalised manner. While places create a social whole, non-places create a contractual solitude. On entering non-places, the individual is recognised through means of identity; once inside, he interacts only with texts (record-cards, distributors, displays), without any human intervention. Words are almost no longer needed. In non-places, the user is always required to prove his solvency or, more generally, his innocence. Stripped of his habitual self-determination, he is reduced to playing the single role of the user; in an eternal present, he coexists with distinct individualities that are all alike and undifferentiated from one another, in a kind of enormous parenthesis, outside of any organic society.
The non-place embodies the realisation of the Puritan ideal:
- detachment from the outside world, which is regarded as useless, evil and conducive to the temptations of magic and idolatry; from tradition, which is the bearer of falsehood and idolatry; from human relations, which lead to temptation, time-wasting and fallaciousness; and from the self, for the same reasons;
- total solitude, which stems from the fact that the above-mentioned relationships are forbidden;
- contract as the only modality of relationship, in that it is orderly, predictable, regulated by laws and safe from the snares of spontaneity. Any attachment is seen as deifying the creature, and as an obstacle to the total mobility demanded by the rationalisation of work and of the world; it must therefore be despised as irrational, fought against and eliminated.
Thus, modern science was not born out of nothing; it emerged from a violent polemic against magic (De Martino, 1948). Not only Nature, whether organic or inorganic, has to be stripped of every semblance of animation and vitality, but also man and his cultural output must be interpreted according to criteria that are mechanomorphic, not anthropomorphic. From the methodological standpoint, guarantees of objectivity are never enough; new guarantees are always required in order to prevent disturbing subjective elements from creeping in. It is, however, clear that the range of controls cannot be enclosed by an external, absolute guarantee (which does not exist) and that there will always be the doubt expressed by the question Quis custodiet custodem ?
The final objective, then, continues to lurk in the background, more or less explicitly, especially with regard to subjects in which there is a strong human presence (ethnology, history, psychology), that is to say, combating superstition, cleansing the mind, purging it once and for all of the shadow of error (De Martino, 1948). This is a form of methodological monotheism, according to which there is only one form of knowledge, i.e. scientific knowledge, which has an absolute compelling value and which must be exported and imposed in missionary style according to a logic that implies the measurability of all the components of reality and the determinability of everything. The application of this criterion is not unlike some of the effects, veiled or explicit, of terrorism: be operative, i.e. measurable, or disappear (Lyotard, 1979). Scientificness (or rather scientism), as it has the means to make itself into reality, is also able to administrate its own proofs; it is from this that its credibility derives. Its aspiration to a unitary, totalising truth lends itself to unitary, totalising practice.
On the other hand, it is well known that scientific knowledge is not all knowledge (Lyotard, 1979); there are many other types of knowledge, including savoir-faire, knowing how to live well or to listen, which exceed the application of the single criterion of truth, and which extend to the criteria of justice, happiness and beauty. The individual is made up of various kinds of skills which make him an incarnate unit.
Lyotard shrewdly notes that narrative-type knowledge displays a certain tolerance towards scientific knowledge, while the opposite is not true. The scientist investigates the validity of propositions of a narrative (or other) type and finds that they have not been subjected to argument or testing. He classifies them as products of another mentality: wild, primitive, underdeveloped, backward, alienated, based on opinion, on customs, on authority, on prejudice, on ignorance, on ideology (Lyotard, 1979). They are merely fairytales suitable for women and children. Attempts are made to civilise, educate and develop this obscurantism. From the Reformation onwards, modernity has been characterised as being dominated by the idea of history as progressive enlightenment, which develops in accordance with the ever greater appropriation and re-appropriation of the foundations; these latter are often thought of as the origins (see the return to the Bible), so much so that theoretical and political revolutions are proposed and justified as a return to the origins. The course of thought is conceived of as a progressive development in which the new is identified as the only value through the mediation of the recovery and appropriation of the origin-foundation (Vattimo, 1985). Being modern becomes a value, indeed the fundamental value against which all others are measured. Modernity appears to reject the sacral view of existence; in reality, however, it replaces it with faith in progress, which purports to be a recovery of the Judeo-Christian view of history from which the transcendental references have been removed. This is a secularised faith and a faith in secularisation, a religion of the historical process, which is identified with pure and simple faith in the new.
Continual renewal becomes necessary for the survival of the system; novelty becomes routine. It no longer contains anything innovative, but enables things to go on in the same way. No one can fail to see the inevitably and necessarily destructive effect of this mindset, which, in order to justify itself, must always find old ideas and practices to eliminate and to supplant, and which ends up by becoming self-destructive, in the sense that it feeds at an ever accelerating rate on the destruction of what it has created; it questions everything except its own premises, which are taken to be the only ones possible. The final objective is to achieve the most radical non-historicity, in which existence is reduced to the naked present. The old, meaning existing and pre-existing reality, is always and in any case a negative value that has to be eliminated, either because it is a dead weight, a falsehood, a useless burden, or because it has been thought up by an oppressive authority whose only aim is ignorance and enslavement. From this perspective, we can see how EBM strives to present itself as an epistemological revolution, as a new method that aims to discover the true drug, which lies beneath everything, hidden by traditional practices and by the incrustations of routine.
Truth is discovered through elimination and exclusion, rather than by integration. In this sense, human nature, which, it should be remembered, is driven to evil, lies and self-deception, can be uncovered by stripping away all of the layers superimposed upon it by the enactment of roles and the condition of belonging. What we have is homo natura, whom we can come to know through progressive techniques of unmasking. As observed by Binswanger (1933), the notion of tabula rasa (if not of the clean sweep or of scorched earth) is never a starting point, but always a point of arrival; that is to say, it is the final result of a dialectic which restricts and reduces the totality of human experience to a particular modality of experience. This results in the complete interchangeability of human beings, who are seen as neutral and universal, bereft of individual specificity. Common human essence can only be found if we somehow go back beyond the historical differentiations that have led us away from it. Try starving a large number of people who are extremely different from one another. As the dominant need for food becomes more pressing, all individual differences will vanish and their place will be taken by the uniform manifestations of that single unsatisfied drive (Freud, 1912). These words sound prophetically sinister, beyond the intention of the author. The concentration camps, which they inevitably evoke, seem to have been the logical realisation of this vision, carried forward without compromise or hesitation, by systematically stripping people of everything clothes, name, family, history, links with their place of origin until they became an undifferentiated mass of raw material for the production of corpses. The idea that is implicit in this view of human beings is that they reveal what they really are in conditions of great stress, deprivation or scarcity, according to Hobbes test, or else in conditions of absolute isolation from their habitual life, i.e. in experimental conditions. However, as Williams (1979) points out, conditions of stress and deprivation are not ideal conditions in which to observe the typical behaviour of any animal, nor to observe other characteristics of human beings. The individual that Hobbes had in mind was isolated from any bond of family or community, and even from himself. Having emerged from the Reformation, he was solitary and withdrawn, and had no pleasure whatsoever; on the contrary, he was much pained by the company of others unless he had the power to intimidate them; greedy only for unlimited power, he constantly competed for success. By excluding in principle the idea of humanity and solidarity, and by hypothesising a state of perpetual war of everyone against everyone else, a condition that was estranged from the human contract, Hobbes prepared a perfect theoretical basis for subsequent ideologies.
Throughout the process of secularisation (Gehlen, 1957), religion has been criticised; however, its fundamental categories have been absorbed unaltered into scientism. Scientism has, in turn, been utilised to justify totalitarian ideologies, which have always been presented as scientific. Such ideologies claim to explain everything on the basis of presumed laws, according to a coercive logic that demands the elimination of everything that does not conform to its premises, and which regards all that does not conform as outmoded and defeated in a competition in which only one truth is possible. All outlets, both of knowledge and of action, are sealed off, except for the single outlet imposed by the ideology itself. The features of this form of totalitarianism are the annulment of pluralism and difference, artificiality and absolutism. The evolutionist vision refuses to accept or even to consider anything as it is and interprets everything as a stage of some further development (Arendt, 1951). Totalitarianism aims to eliminate any feature that cannot be subsumed under a universal law (in the case of EBM, the coexistence of different methods and drugs old and new the desire for human contact on the part of the patient and physician, etc). Totalitarianism replaces the channels of communication among individuals with iron fetters, which bind them so closely that their plurality disappears (Arendt, 1951). Freedom and contingency must not be allowed to hinder the process; a supersense is created, which obliterates common sense. As the whole of reality must be brought within the system, the system must be rendered impervious to confutation by reality. If any contradiction emerges (e.g. the acclaimed new drug is worse than the old one or has serious unforeseen side-effects), this depends on the as yet imperfect application of the method, which is, in itself, perfect. Facts are arranged in a logical mechanism that is based on an axiomatically ascertained premise; everything else is deduced from this in accordance with a coherence that does not exist in the real world. The process aims at unlimited expansion; it has no end or objective other than itself. This absoluteness brooks no objection from the individual conscience. While traditional authority, in whichever of its forms political, religious or cultural aims to reduce or curtail freedom, but not to abolish it, totalitarianism seeks to destroy human spontaneity in general; it is not content merely to limit freedom, however tyrannical that may be. The end that is always kept in view is total dominion; all territories must sooner or later be annexed. When science is ideological, it is no longer controlled by reason and becomes refractory to factuality. Personal motivations and passions are banned, not for reasons of cruelty, but in the pursuit of perfect impersonality. In the concentration camps, doctors, engineers and gas chamber technicians continually introduced improvements, designed not only to raise the productivity of the corpse factories, but also to alleviate the agony and hasten the death of the victims.
In reality, totalitarianism aims to make people superfluous (particularly doctors, who can be replaced by drug dispensers); it aspires to turn individuals into zealous bearers of a universal natural law, with which they would otherwise comply only passively and unwillingly. It promises to reach objectives by discarding the action and the will of man, through procedures that are as impersonal as possible. It wishes to cast aside the pre-existing world in order to liberate and accelerate the impersonal forces of evolution and history. Banishing dissent means that an initial premise gives rise to coherently deduced consequences, regardless of any contradictory experiences, which can communicate nothing new. Thus, a truer reality is held to be hidden behind those things that are directly perceptible, and which are considered misleading. Individuals therefore lose confidence in themselves, in their own thoughts, in others and in the world. The ideology becomes the only source of truth. Once we have lost the reciprocal guarantee constituted by common sense, which is necessary in order to gain experience and live in a shared world, the elementary norms of compelling evidence are the only ones possible. By destroying all dialogue between individuals, the ideology forces us to build on a single premise; if we abandon this single basis, which is apparently made up of logical reasoning, we feel lost. This organised alienation contains a destructive principle which, however, as it accelerates, leads to self-destruction.
One of the arguments put forward in favour of EBM is ethical: that it is our duty to try to provide the patient with the best possible treatment. This assertion is, however, questionable, as the following case illustrates.
The case in question is well known and has often been quoted in the literature. It concerned a new treatment for persistent pulmonary hypertension (PPHS), a disorder which at that time displayed a mortality rate of over 80% among the newborns affected. The treatment, called ECMO (extracorporeal membranous oxygenation), was introduced at the end of the 1970s. At the Michigan Institute, where ECMO was implemented, PPHS mortality rates monitored over several years were below 20% among treated newborns. Despite the fact that the researchers expected the majority of ECMO-treated patients to survive and the majority of those treated with the traditional method to die, they were obliged to carry out a randomised controlled trial (RCT) in order to obtain scientific evidence of the efficacy of ECMO. In order to avoid a slaughter of babies worthy of King Herod, they decided to utilise a modified protocol, named Play the Winner, according to which recruitment was skewed in favour of the method that led to the survival of the treated newborn. The trial enrolled 12 babies: 11 treated with ECMO, who all survived, and 1 treated with the traditional method, who died.
The results of this study, however, were not considered to be convincing, since only one patient had received the conventional therapy. A second trial was therefore undertaken, this time through orthodox randomisation; a cut-off was, however, imposed: the study was to be terminated if 4 deaths occurred in either the experimental group or the control group. As expected, the 9 patients assigned to the ECMO group survived, while 4 of the 10 babies allocated to conventional treatment died. Moreover, it should be pointed out that, according to a strict interpretation of the criteria of statistical significance, this second trial had also failed to yield scientific evidence.
This account, in addition to being emblematic, is extremely disturbing and prompts several considerations, especially with regard to the relationship between ethics and scientific methodology. It seems clear that, as soon as we take for granted that only one criterion for obtaining scientific evidence exists (in this case, a correct randomised controlled trial), all ethical objections are brushed aside. In the case of ECMO, for example, the death of five newborn babies was not only justified, from this perverse standpoint, but actually proved to be insufficient with regard to the noble aim of objectively demonstrating the efficacy of a treatment that simple good sense had already ascertained to be effective.
Furthermore, in the above-mentioned RCT, the management of informed consent also revealed an ethical aberration. Only the parents of ECMO-treated babies consented to participation; the parents of the babies who underwent the traditional treatment did not know that their children were taking part in a study and, especially, that the researchers were aware of the existence of a much more efficacious therapy, which would probably have saved their childrens lives.
In a far less dramatic and decidedly ironic vein, we cannot help thinking of the article by Gordon C. S. Smith et al. (2003) in which the authors point out that the effectiveness of parachutes in preventing death caused by falling from great heights has not been scientifically proved, in that it has not been subjected to rigorous evaluation through randomised controlled studies. The authors conclude that we would all benefit if the most radical advocates of EBM were to design and take part in a double-blind randomised controlled study of the efficacy of parachutes.
The ethical doctrine that implicitly underlies EBM is utilitarianism. As much as EBM seems to be diametrically opposed to a religious, and especially Puritan, vision (or perhaps precisely because it is diametrically opposed), it conserves roots that are inspired by this worldview. As we have seen, Puritanism purports to seek utility, meaning the practical realisation of improvements to the world. According to utilitarianism, there is only one principle: the greatest happiness of the greatest number of people. Here, happiness means pleasure and the absence of pain; the only moral principle precisely because it is the only moral principle must be applied to every particular situation. The rightness or wrongness of an action depends always and only on its consequences (Williams, 1972). There is no room for doubt: achieving the greatest possible happiness is an unquestionable objective, whatever else may need to be sacrificed in order to achieve it.
The main attraction of utilitarianism is that moral problems can be solved through the empirical calculation of consequences. Everything becomes quantifiable, and all moral difficulties become a question of technical limits to the possibility of calculation. The differing needs of the parties involved can be converted into a common measure in terms of happiness. Conflict is impossible because everything can be reduced to the principle of the greatest happiness by identifying the best course of action after assessing all the consequences, even if this leads to an illicit action according to other moral criteria. The aim becomes that of completely eliminating conflicts of value; the system strives to achieve efficiency, and conflicts are a sign of inefficiency. However, happiness can only be a common measure if it can be calculated, compared and summed; in other words, treated in arithmetic terms. Since this concept conflicts with other values, utilitarianism reacts by questioning these more problematic values, considering them irrational or throwbacks to past eras. Utilitarian rationality becomes the test-bed on which to eliminate the kind of happiness that constitutes an objection to utilitarianism. Values that cannot be quantified are compared with values that can be quantified in terms of resources and cost/benefit ratios. Utilitarianism favours all that is quantifiable in money terms, since monetary quantification is the only admissible form of evaluation, i.e. the measurability of all values. When applied to the individual case, utilitarian calculation is often morally wrong, as when the conviction of an innocent person is deemed necessary in order to avoid further damage. Indeed, utilitarianism urges us to think exclusively in terms of calculable consequences and to disregard traditions, established practices, rules of principle and so on. If there is greater utility in violating, rather than observing, a given rule of traditional morality, not violating it becomes sheer irrationality. An example of this attitude can be seen in the study conducted by a utilitarian, who demonstrates that public executions should not be reintroduced because they do not deter crime, but who does not consider the question of whether or not executions should be reintroduced under any circumstances. All human qualities that are not amenable to a utilitarian treatment, such as spontaneity or the rejection of experiments on humans, are condemned as an irrational heritage.
The unmitigated acceptance of rigidly utilitarian norms was expressed in the writings of a 17th-century Puritan author. The inventions of the compass, printing and gunpowder were examples of progress. These inventions were useful, efficacious and economical; therefore, they were good. We have a means of killing our enemies that is more effective, speedy, economical and frugal than bows and arrows, spears, axes and lances
(Merton, 1967). It is not necessary to underline the resemblance between this assertion and those of totalitarian regimes, according to which what is right is what is good or useful for the whole, as distinct from its parts. Moreover, in totalitarian regimes the liquidation of individuals is viewed within the framework of a historical process whereby the inevitability of certain events is determined by immutable laws; these events must therefore be enacted or endured.
According to utilitarian criteria, which underlie the practice of EBM, experiments in which babies die in order to validate a treatment such as ECMO in accordance with the criteria of EBM, even though other scientific criteria have already demonstrated its efficacy, are necessary; they are not accidental, but obligatory. In the case of ECMO, one author, Worrall, who reported on the experiment, weakly objected that newborn babies are not really sensitive to the placebo effect, and that therefore it was not necessary to design a study in order to determine whether the efficacy of the treatment was due to the therapy itself or to the power of suggestion. But, as Worrall says in perfect good faith, if it had been possible to demonstrate the efficacy of ECMO without applying EBM criteria to the research, the death of these children would have been useless; this observation suggests that, in other cases, their deaths might have been considered useful. Quantification at all costs appears to be pursued in accordance with a faith in a single scientific and ethical criterion, in the search for utility in an impersonal sense, in order to demonstrate ones success to oneself and to others, rather than to respond to the real expectations of ones neighbour.
Then again, from a Puritan standpoint, medicine displays the perennial scandal of the placebo effect, which is in practice the only drug whose efficacy has been incontrovertibly demonstrated, and against which all other therapies are tested. Indeed, the patient benefits from a relationship that is human, and also characterised by a feeling of trust, rather than rigidly regulated in a contractual fashion. Here, too, the creature is deified. It therefore comes as no surprise that increasingly sophisticated criteria are used in the stubborn attempt to annul and isolate the placebo effect, or to quantify it in comparison with that of true drugs; at the same time, the fact that medicine is, or should be, a discipline that integrates tradition with innovation and scientific data with personal relationships goes unrecognized.
We may well wish that those who uncritically embrace the EBM philosophy might undergo the same transforming experience as the lawyer Hector Loursat, the protagonist of The Intruders by Simenon:
Had he ever really noticed anything? He lived on lofty sentiments, like those in tragedies; and when he had loved, he had done so absolutely, without making any concession to doubt or banality.
But then, a shot rings out in another room, and he realises that his house has become a den for a gang of kids! He sets out to scour the city in pursuit of them
And so it is that he discovers people, smells, sounds, shops, lights, feelings. A whole seething mass of life that has nothing in common with that of the tragedies: absurd, indefinable relationships between people and things, charming idiots, gusts of wind at street corners, a passerby lingering, a shop left open for no apparent reason, and, standing under a large clock that is familiar to everyone, a boy nervously waiting for a companion who will open the door to his future
From that moment on, Loursat was a changed man; freed for ever from a virtual world that was populated by abstract concepts but bereft of life, he could no longer go back to what he was before.
|Concept of predestination. The elite are chosen by God; the damned have no means of redemption. The elite have no inclination to help those who are presumed to be damned, but look upon them only with hatred and contempt.
||EBM as a single absolutist model outside of which there is no salvation, but only prejudice, obscurantism and superstition. No indulgence for those who do not adhere apodictically to the model, but only contempt.
|Tends to rationalise the world, which is stripped of everything regarded as a useless bauble (subjectivity, emotion, personal relationships, passions, sensual pleasure). It ends up eliminating irrational impulses (irrational from this point of view) and attachment to the world and to nature.
||EBM regards all subjective information as worthless and dangerous; it is not only useless, but actually misleading.
|Bewährung, meaning experience and proof of salvation, is constantly verified through testing by means of religious diaries, in which progress is monitored in the form of tables and statistics.
||EBM proposes a hierarchy of information in which quantifiable data predominate: evidence counts much more than experience. All that cannot be measured either does not exist or cannot be utilised.
|Despairing view of the human condition (and of the world). Man lives in overwhelming solitude, reduced to his rational and impersonal components.
||EBM delineates a grey, one-dimensional world without nuances, which deeply mistrusts nature, complexity and all that renders each human experience unique and unrepeatable.
|Belief in the existence of an immutable law is present in the doctrine of predestination: the law is there and must be discovered. Predestination is a fact, in the sense in which this word is used in the natural sciences; there is faith in the validity of a single basic postulate.
||EBM starts out from the assumption that there is an objective truth; if it cannot be fully grasped, this is only because the instrument is imperfect. Blind faith in the method and scant attention to the negative consequences that individuals may suffer.
|Reason takes on a particular importance because it serves to repress appetites and because the constant application of rigorous reasoning curbs the inclination to idolatry. Everything must be scrutinised rationally; reason is endowed with coercive authority, and science becomes an imperative duty. Nothing is left as it is, or believed without being subjected to examination.
||Common sense and data yielded by experience have no value unless they are transformed into numbers.
|Tradition, authority, culture and history are viewed with suspicion, as they lead not to truth but to deception; truth is to be found at the origin, before Holy Scripture was subjected to interpretation and distortion. According to the principle of the validity of Holy Scripture alone, the truth-bearing value of traditional practices is denied; the Bible is instituted as the only reference, without mediation. The notion of a single criterion as the source of knowledge is taken up by science; this leads to the rejection of other forms of knowledge, which in the Renaissance period were grouped under the heading of studia humanitatis, and which do not fit in with the new idea of exact science.
||Downgrading of classical psychiatric literature, existing clinical practice, communication with colleagues and patients, common sense and all data derived from the cultural, emotional and human components of the context.
|Nature must be probed by means of extremely active methods. In the words of Francis Bacon, who used metaphors derived from the techniques adopted during the interrogation and torture of alleged witches, Nature manifests itself better under torture and through the use of (mechanical) artifices than when it is left to itself. It must be subjugated, enslaved and imprisoned. It must be forced out of its natural state, squeezed and moulded.
||EBM attaches scant value to naturalistic observations, favouring research methods that force reality into rigid, simplified schemes.
|Suppression of the sacred and of the spirit extends to all places, not only natural but also human (historical, religious, urban), depriving them of all value, making them infinitely available to any form of manipulation, and turning them into de facto non-places.
||EBM research focuses only on that which constitutes a case, or exists as such: everything is treated in the present; distinct individualities, undifferentiated from one another, are seen as existing contemporaneously, in a sort of immense parenthesis, outside of any organic society.
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(1) Psychiatrist, Mental Health Department N.3 - Genova (Italy)
(2) Psychiatrist, Mental Health Department N.2 - Savona (Italy)
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