Evidence not ideology
BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7520.0-h (Published 06 October 2005) Cite this as: BMJ 2005;331:0-hAll rapid responses
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The discussion on ideology and evidence is interesting, because the
two concepts carry the key to conflicts in many issues. The key to
understanding this conflict is the basis on which the principles are
founded. Ideology is based on belief that something is good or wrong,
while evidence should be based on documented knowledge. Already now it
seems clear that ideology and evidence are of extremely different nature.
Within health care ideology frequently refers to political decisions
or ideas. The quality of these ideas may be very different, but are
frequently based on an intention to provide health care for the
inhabitants. Ideology thus is combined with an intention to do something
and founded on belief.
Evidence is or should be based on knowledge, documented principles
and documented results. The evidence concept thus carries knowledge on a
necessary sequence of events. In modern medicine evidence is a long wanted
concept, based on which standard in medical care can improve.
The third concept, assumptions, refers to what is not known, but
assumed to be correct. It is however not necessarily correct. An
assumption can thus be used as a hypothesis, on which new research is
based to refuse or accept the assumption as false or true.
These are some areas within health care, where ideologies are best
substituted by knowledge and knowledge derivation based on assumptions.
Examples are well known. One is the scenario with the many new diabetes
patients launched by different research groups and based on their studies
in different and focussed intervention groups combined with application of
different diagnostic procedures and diagnostic limits.
It is confusing and complicate planning of health economy critically.
It is possible with approved guidelines and applied methods to recruit up
to several million new EU citizens with diabetes with one guideline
compared to few with another guideline.
The conclusion seems to be – without referral to the specific NHS
decision – that ideology is not valid for planning or intervention. it may
serve as a tool among others to create new ideas. Base on these
assumptions may arise and be refused or confirmed. First hereafter
evidence is a present and a valid tool for intervention in health care.
Lone G.M. Jørgensen
MD, Dr Med Sci, specialits in clinical biochemistry, researcher
Competing interests:
None declared
Competing interests: No competing interests
I agree with Julian Tudor Hart's contention that all evidence is
conceived and perceived through an 'ideology'. Reading Marx made this
clear to me, but other philosophers might use the more acceptable phrase
'theory of knowledge'. The term 'Ideology' is (mis-)used today to imply a
left- or right-wing political mindset which somehow prevents people from
seeing the 'objective evidence' for what it is - with the corollary (to
which Fiona Godlee subscribes) that those 'neutrals' unencumbered by
ideology could somehow be the more objective !
My political ideology is socialist. I prefer the NHS to the US
system. But I do believe that other systems (eg. the Swedish) have some
better features.
Tell me Julian - are GPs 'private' ? or 'being privatised' ?
If the NHS contracts for secondary care ( eg: cataract surgery)
through self-employed doctors in wholly-owned secondary care doctor co-
ops, or private hospitals, how shall we describe it ?
- privatisation or sub-contracting ?
Personally, I believe the GP subcontractor model WAS a very efficient
saving-grace of the state-run NHS. I do prefer that 'socialised health-
care' should proceed in fair competition in the mixed economy of a free
society, rather than the Stalinist alternative.. In fact - I am certain
that we are succeeding at it - which is the main reason why the New Right
is still scratching around for alternatives !!
it IS still working..
Competing interests:
I am a GP contracted under nGMS to the UK State NHS
Competing interests: No competing interests
Fiona Godlee asks for evidence without ideology, as though it were
possible either to discover or use evidence without ideology of some kind.
Scientific evidence is derived from hypotheses conceived within an
ideology, that is, a set of prior assumptions about the real world,
established by previous evidence, and/or by faith. New evidence can then
be produced by testing hypotheses derived from those assumptions against
reality. The validity of competing hypotheses, including those macro-
hypotheses about the world or society we call ideologies, depends on their
explanatory and predictive power in the real world.
About the Private Finance Initiative and the Blair government's
disintegration of the NHS into a competitive market led by consumer wants
rather by national health needs, nobody has published more evidence than
Allyson Pollock. For the editor of the Britsh Medical Journal (BMJ)to
dismiss this as led by ideology is an impertinence. Without exception,
every paper published by the BMJ starts from ideological assumptions of
some kind. That the editor's assumptions apparently coincide with those
of currently fashionable and conventional opinion does not change their
ideological nature. Readers can make their own judgements as to which
ideology has most explanatory and predictive power, either experimentally
or in the more chaotic real world of practice, which in the absence of
pilot projects is all we have to go on in assessing the consequences of
marketisation.
This is a deadly serious business. Asked to describe the nature of
the Corporate State in the 1920's, before the full consequences of fascism
were understood by comfortable people outside Italy, Benito Mussolini
answered that in his State the worlds of government and business would
become one and indivisible. Fiona Godlee should consider how far we have
already travelled along that road; and then to reconsider the ethics of
neutrality in such a situation. At the birth of the NHS, the BMJ played a
role of which its later editors were frankly ashamed. Today, when the NHS
is being buried alive, has it lost the power of speech?
Julian Tudor Hart
Primary Care Group, Swansea University Clinical School
julian@tudorhart.freeserve.co.uk
Competing interests:
None declared
Competing interests: No competing interests
Evidence not idealogy
Having read the extensive discourse in this journal on the topic of
current NHS "reforms" I remain somewhat confused. The increasing
complexity of organisation in the NHS and the lack of accountability or
transparency in its decision making is such that it now almost defies
analysis. In such opaque times I would like to offer up a single, yet
highly significant fact that I think distils the current predicament.
In the last ten years hospital bed numbers have been reduced in spite
of
unprecedented increases in healthcare funding and an inexorable and
unavoidable increase in demand for emergency hospital beds.
I do not think that this can be reconciled.
I may be wrong, but I can only conclude that this implies massive
waste,
misappropriation of funds or an ignorance of clinical priorities. We now
have an industry of people whose remit is to redesign, direct and
manage our healthcare. Perhaps one of them could enlighten me and
the British public on how this happened.
Competing interests:
None declared
Competing interests: No competing interests