 |
|
Eivind
Engebretsen
The
medical concept of evidence and the irreducible singularity of being
I will
first like to thank you and the other organizers and initiators of the Kristeva
Circle for planning and setting up this wonderful event. It is a great honor
for me to be invited to participate in this celebration of one of the greatest
intellectuals of our time.
I had
the great pleasure of working with professor Kristeva some years ago, first by
initiating the Norwegian translation of her Open Letter to the President of the Republic
on Citizens in the Situation of Disability and later
by organizing the Julia Kristeva
Days in Oslo in 2009 which through a series of events drew attention to the
socio-political aspects of Kristeva’s thought focusing mainly on her work on difference
and disability. This event also resulted in an anthology in Norwegian containing
contributions by Kristeva herself as well as other prominent French and
Scandinavian researchers within this field.
It is
also this collaboration that has inspired the topic of today's talk. Although I
have a background in the human sciences myself, my principal engagement with
Kristeva's thought has been about arguing and demonstrating the relevance of
her concepts and approaches for other disciplines outside the humanities, such
as social policy and medicine. By medicine I do not only mean psychoanalysis
where her thought has an unquestionable role. I am convinced that Kristeva's
thought has a unique potential for challenging and rethinking key concepts and
fundamental presuppositions within modern medicine more generally. This
conviction is the point of departure for this talk.
I will however
start somewhere in between literature and medicine and with a quote from a quite
famous medical record:
(Memory?)
“I remember the very last days, of course.” (11 x 12?) “Oh, I have never been
good at sums, professor, once I calculated myself out of 5000 kroner, another
time I calculated myself a gain of 1000 kroner. Even though I worked as a shop
assistant as a youngster.” (7 x 9?) “63” (What did your parents die from?)
(Langfeldt quoted in Aastestad 2009)
This
quote is drawn from the medical record of the Norwegian novelist Knut Hamsun.
As you would know, Hamsun was interned at a psychiatric clinic after the Second
World War as a consequence for his support to the Nazis in order to assess his
mental state.
As the
Norwegian professor of comparative literature Petter Aaslestad has noted, this
report reveals “an impenetrable wall" between Hamsun's own "and his
psychiatrist’s ‘vision du monde’” (36.) We can see from the quote a contrast
between the mechanic questions of the doctor and the playful answers from the
novelist. At the same time, this playfulness reveals a struggle. A struggle to keep his autonomy in the most literal sense, of
course. But also a struggle to escape categorization. A struggle to keep his irreducible singularity, to be
differently different.
The
issue of singularity, otherness and difference is a conducting line throughout
Kristeva's diverse authorship and most of her famous analytical concepts such
as the semiotic and the symbolic, the abject, and of course strangeness or
foreignness are related to this topic. In later years, this interest has also
found a somehow more concrete and private expression in her work on disability.
In the
article "A tragedy and a dream:
disability revisited" (2013) Kristeva traces our understanding of
difference and disability back to the Aristotelian concept of 'steresis', a
lack or a 'privation of having'. Blindness is for instance conceived as an incompleteness, a lack of being, in one who by nature
sees. This ontology of privation found echo in Christian humanism and inspired
the Christian idea of charity as an act of completing or giving to those who
have not: “various 'steriles', defective or poor, share powerlessness in
suffering and passion, and in our com-passion with the 'lack of being', we
establish 'good living', the ethics that will be Christian humanism”, Kristeva
explains. However, as Kristeva argues, the idea of disability as a lack of
being is not only visible in charity work but also "on the level of
knowledge", "through the study of the 'empty' (pathologies)"
through which "the sciences appropriate the complexities of the 'full'
(normal functioning)". She develops this argument as follows: “Being is
perhaps no longer the Divine, but we have replaced it with Biology, when we
understand the disabled person as ‘lacking’ certain biological aptitudes”.
Construed around the master dichotomy of having/not-having, medical discourse
has developed into a machinery of dividing practices through which those who
are different are reduced to what Kristeva refers to as "categories of
difference". Their lack, their state of non-being, makes them different in
the same way. As Kristeva points out in her Letter to the president: Medical
discourse "blends all disabled people together without taking into consideration
the specificity of their sufferings and exclusions". This way medical discourse
represents an exclusion of the deepest kind, an exclusion of the “incommensurable
singularity of each person”.
In this paper I want to develop this criticism further. I
want to show how Kristeva’s criticism goes beyond the standard criticism of the
“medical model” (as opposed to the social model). It is also a criticism at the
level of knowledge and goes to the core of the medical
concept of evidence. I will argue that modern medical discourse is construed
around a notion of evidence which has excluded the
subject and singularity. I will first outline the overall logic underpinning
the current model of evidence-based medicine. Second, I will show how attempts
within medical discourse to approach the individual are performed in a way that
repeats the same fetish for generality and excludes singularity. Finally, I
will argue that Kristeva’s theories lay the foundation for an alternative
medical epistemology, an epistemology of the irreducible singularity of being.
The current construal of EBM is
grounded in epidemiological and statistical reasoning. The ultimate method for
creating evidence is the so called
randomized controlled trial (RCT) in which patients are randomly assigned
to a treatment group that is exposed to an intervention and a control group
that is given a comparable intervention or a placebo. The aim is to determine
whether the intervention is more effective on a group of patients than other
interventions or lack of intervention. How the intervention works, when, why
and on which patient is considered less relevant. The logic is that the larger
the group the less such questions matter. Ideally, results from RCTs should be
aggregated through the use of statistical meta-analysis and subsequently form
the basis for clinical guidelines recommendations to clinicians with
probability estimates of each outcome.
Central
to the EBM framework is also the
evidence hierarchy (often illustrated as a pyramid) with the
highest-quality evidence at the top and the lowest-quality evidence at the
bottom. On the highest level are RCTs and meta-analyses of RCTs and on the
bottom case studies and anecdotal reports. This hierarchy corresponds with a
movement from individual to group, from singularity to generality, from a
variety of difference to categorized difference. The evidence grows into being
and in strength through a process of purification through which singular
differences are gradually ruled out and the only ontologies that remain when
the top of the pyramid is attained are unified categories of difference
(treatment or not treatment, diagnoses or no diagnoses etc.). In this sense,
evidence-based medicine is the name of a process in which individuals are
gradually replaced by conditions and singular difference by ‘categories of
difference’.
Hence,
medical evidence is by definition concerned with groups or what Kristeva refers
to as ‘categories of difference’. For a claim to obtain status as evidence, it
must be proven true for a large group of individuals (a population). Moreover,
what is true for a group is also considered to be true for the individual
patient. Evidence is supposed to be moved from group to individual (from bench
to bedside) through so called “knowledge translation” which designates the
“exchange, synthesis and ethically-sound application” of evidence. The process
of “knowledge translation” hinges upon the mobilization of a chain of textual
genres – starting with RCTs, followed by meta-analyses or systematic
reviews (summarizing the scientific state of the art) and culminating in
clinical guidelines, which prescribe manners of intervention in concrete cases.
It is assumed that all these textual genres transmit the evidence in
increasingly condensed and vernacular forms without threatening its universal
and general character.
It is
also fundamental to the medical concept of evidence that it is external to the
clinical decision. David Sackett, one of the pioneers of evidence-based
medicine described it as an “approach that integrates the best external
evidence with individual clinical expertise and patients' choice”. Evidence
is "external" to the individual case, external to the concrete act of
relating and to the singular being. This evidence that is external and general
is contrasted with clinical expertise and patients’ choice
which are “individual”. These two latter terms are, though included in the EBM framework,
excluded from the concept of evidence as such. Evidence-based decisions are
based on three sources: External evidence, clinical expertise and patients’
choices. Clinical expertise and patients’ choices should be integrated with
evidence but do not count as evidence.
This does of course not mean that modern medicine is not
concerned with the individual. On the contrary, there
are many knowledge practices within modern medicine which aim to put the individual at the center of care. Still, these initiatives tend
to repeat the same mechanisms of exclusion. "Patient involvement" is a key word within modern medical
discourse. WHO states for instance in a Policy Brief entitled “Where are the
patients in decision-making about their own care? (2008) that “patients can play an important role in understanding the causes of illness,
protecting their health and taking appropriate action, choosing appropriate
treatments for acute episodes of ill health, and managing chronic illness.
These roles must be recognized and supported” (WHO Policy Brief 2008). This
overall policy is translated into three more specific interventions: 1) health
literary, 2) shared decision-making and 3) self-management / empowerment.
The first of these three strategies “health literacy involves the ability to
read, understand, evaluate and use health information to make appropriate decisions
about health and health care”. On the one hand, the patient is here
placed at the center of decisions about health and health care. On the other
hand, in order for the patient’s voice to be valuable and to form the basis for
“appropriate decisions”
it must be framed by the right knowledge. The individual voice is thus not
valuable as such but only as carrier of general knowledge or evidence. Only the
literate voice, a voice that is docile and shaped by the medical discourse
itself is included in decision making. The concept of
literacy privileges a voice that is framed by rationality, logic, syntax,
signification and representation - what Kristeva in her early work referred to
as the symbolic aspect of discourse. At the same time, the call for literacy
excludes - in Kristeva's words - "other aspects of “meaning” which are
more than mere “significations”, the semiotic, such as rhythmical and melodic
inflections of the suffering and singular speaking body, but also irrationality
and resistance that mark out the illiterate and excludes his or her voice as
"inappropriate" for decisions.
The second strategy, shared decision making is
described and defended in the following way: “One of the most common
sources of patient dissatisfaction is not feeling properly informed about (and
involved in) their treatment. Shared decision making,
where patients are involved as active partners with the clinician in treatment
decisions, can be recommended as an effective way to tackle this problem. […]Evidence-based patient decision aids facilitate the
process of making informed decisions about disease management and treatment”.
The aim of so called "shared decision making" is to involve the patients as active
partners. At the same time, “shared decisions” are framed by “evidence-based patient
decision aids”. Typically, the patient is presented to an option between treatment
X and Y based on probabilistic estimates of outcome deduced from current
research evidence. Hence, the interaction between the patient and the care giver is reduced to the weighing of evidence. The
encounter is purely contractual governed by a “logic
of choice” and a symbolic language through which the doctor provides
"objective" information about the patient's condition. Once again,
what is excluded from the encounter is the contactual aspect, the individual
act of relating, the singularity of the patient's
suffering and the semiotic elements of his or her speech.
The third strategy mentioned in the policy is to
look “for ways to empower people to manage their own health and health care, by
providing them with effective self-management support”. The concept of
empowerment implies that good health starts with the singular choice of each
individual. Still, the individual is encouraged to be singular in a specific
way. Singularity is translated into autonomy. It should not be lived or
expressed but “managed”. The individual that is included in medical decisions
is an individual that is shaped by the medical discourse itself: a rational
actor that manages his or her own health. Other forms of singularity are categorized
as lacks that should be rectified through empowerment and 'self-management
support'.
We see
from the WHO policy that "patient involvement" is framed by general
norms of standardized knowledge, rational choice and autonomous conduct. The
individual that is included is an individual that fits with a category: the
literate and rational self-managing individual. The singular is created in the
image of the general.
Another
knowledge practice which explicit aim is to put the patient at the center of
care is so called health and symptoms assessment tools. A whole range of measurement
instruments (quality of life scales, pain assessment scales etc) have been
developed in order to categorize the subjective experiences of the patients as
accurately as possible in order to prepare for individualized clinical
decisions.
I will
illustrate this practice using an internationally recognized assessment
instrument used in treatment and care of cancer patients. The
tool is called the Edmonton Symptom Assessment Scale (ESAS) and was introduced
in 1991 as a method for regular assessment of symptom distress (Buera et al.
1991). It consists of a survey form designed to assist in the assessment of
pain, tiredness, nausea, depression, anxiety, drowsiness, appetite, well-being, and shortness of breath. The severity of each
symptom at the time of assessment is rated from 0 to 10 on a numerical scale. According
to the user guidelines, the intention of ESAS is to “bring out the patient’s
subjective experience of their situation” (IS-1529 2007, 18). It is based on
the idea that the patient is an expert on his or her own suffering and that his
or her subjective experience is the “gold standard” for treatment. At the same
time, the ESAS represents a more standardized and supposedly more objective way
of assessing and measuring each patient’s subjective experience and level of
symptom distress. Its explicit aim is “to assess the current symptom profile as
accurately as possible” (ESAS 2010, 3). In line with this purpose, the
guidelines also stress the importance of a “valid use” of the form. The
assessment should, for instance, always be done on the ESAS numeric scale. In
other words, in order to be “valid” and “reliable” the assessment should be
performed in a controlled manner. Subjective and pure patient experiences can
only be grasped through a formal and standardized procedure, it is assumed.
Hence, the form is designed based on the assumption that patients speak more
accurately and adequately through a standardized voice allowing predefined
categories to articulate their symptom distress. This also implies that certain
subjective experiences are excluded as irrelevant or as noise. The form only
allows for subjective differences that can be graded on a standardized scale.
Other differences (such as type or quality of pain) are ruled out. A language
that only emphasizes differences in degree of pain while excluding other experiences
and differences is presumed to be more accurate or pure.
Ideally, the assessment should be performed by
the patient him or herself. If the patient cannot participate in his or her own
symptom assessment, the caregiver should assess the symptoms
“as objectively as possible”, it is stated. In
order to ensure objective assessment, a list of so called “objective indicators” is provided.
The
following are examples of objective indicators:
Pain – grimacing,
guarding against painful manoeuvres
Tiredness –
increased amount of time spent resting
Drowsiness –
decreased level of alertness
Nausea – retching or
vomiting
Appetite – quantity
of food intake
Shortness of breath
– increased respiratory rate or effort that appears to be causing
distress to the patient
Depression –
tearfulness, flat affect, withdrawal from social interactions, irritability,
decreased concentration and/or memory, disturbed sleep pattern
Anxiety – agitation,
flushing, restlessness, sweating, increased heart rate (intermittent),
shortness of breath
Well-being
– how the patient appears overall (ESAS 2010, 2)
The whole concept of “objective indicators”
implies that the caregiver’s subjective interpretation should be ruled out as
far as possible. The caregiver’s subjective interpretation is a potential
source of bias and a threat against accuracy. This threat can be
counterbalanced through the use of “objective indicators.” Furthermore, it
presupposes that symptom experiences have an objective existence independent of
the patient’s own singular interpretations and descriptions of his or her pain.
The form assumes that there is a pure pain experience that exists prior to
language and categorization and that can be adequately measured given the right
assessment tool. Nausea, tiredness, anxiety, and depression are considered to
be distinct and clearly distinguishable conditions that exist independently of
the categories we use to describe them. Such conditions are intuitively
recognizable and do not necessitate interpretation, it is assumed. Symptoms
such as pain, anxiety and nausea thus appear to be generalized and unambiguous
phenomena. They change in degree but not in type. What type of pain the patient
may feel, and whether it is the same today as it was the day before or is perceived as a different pain entirely, is not conveyed.
Such information falls outside the form’s registering gaze. The form does not
solicit information about the causes of fear and anxiety. Only the degree to
which these emotions are felt is made interesting and relevant. Thus, it is
also said that all anxiety and sadness can be treated equally. It is the level
of anxiety that guides the intervention, not its underlying causes or nature.
The singularity of the symptoms is ruled out.
We see that while the patient's subjective
experience is said to be the gold standard for treatment, this subjective realm
is assumed to have an objective and generalized existence beyond the
individual's description of his or her singular sufferings. The truth about the
individual's sufferings (the objective indicators) is to be found outside the
individual. The individual's singular expression of his pain (the semiotic) is
ruled out as noise and falls outside the definition of knowledge. Knowledge is
strictly linked to a symbolic mode of expression, to clear and universal categories.
Some of
the same subtle mechanisms of exclusion can be found in qualitative research
within the medical area. The explicit aim of this type of research is to capture
the singularity of the experience of each individual as well as relational aspects
of health care delivery. Patton (1985) states that qualitative research “is an
effort to understand situations in their uniqueness as part of a particular
context and the interactions there” (p. 1)
In a recent paper, I have together with colleagues explored
the principles of knowledge underpinning a selection of qualitative studies of
rehabilitation interventions and assessed whether the articles adhere to their
own stated principles. The point of departure for our
study was a literature review of research about young adults with disabilities
based on a systematic search in medical databases. After a preliminary
screening, 104 publications were included in the study. Of these, only 12 were
found to apply qualitative methods. While the quantitative papers were subject
to a traditional medical research synthesis with the aim of describing the
state-of-the-art within the field, we decided to approach the qualitative
studies in a different way. Our review might be characterized as
meta-epistemological because it analyzed the knowledge production of the
research articles rather than the knowledge content as in a meta- synthesis.
This implies that we were more concerned with how the articles create knowledge
than what they create knowledge about. We were interested in the principles of
knowledge creation presented in the articles, and how the articles aligned with
these principles. Thus, we were concerned with the explicit and implicit
understanding and structuring of knowledge—the epistemology—
expressed in the articles.
We
found that the articles demonstrate a tension between the qualitative
principles stated in the articles and the way the results are presented. Here I
can only provide a few examples:
Hooson, Coetzer, Stew, and Moore (2013) studied
patients' experiences of return to work rehabilitation following traumatic
brain injury. They took on a phenomenological perspective emphasizing that the
objective of their analysis was to elicit the individual’s unique perception
and understanding of the phenomena (p. 22). However, in the presentation of the
results they were primarily concerned with the quantitative occurrence of
qualitative statements: “Most of the participants (9 out of 10) . . .” (p. 28), “. . . all participants . . .” (pp. 22–23, 25,
28, 31–32, 34, 36), “All 10 participants viewed . . .” (p. 26), and so
forth. Their intention to explore unique experiences where thus partly
undermined by an emphasis on categories of experiences and their frequency.
Self, Driver, Stevens, and Warren (2013) also focused attention upon the individual participant and the explicit purpose
of their study was to determine physical activity (PA) knowledge, attitudes,
intentions, and barriers among individuals . . .” (p. 22). This aim was however
partly undermined by the choice of group interviews as a method. Furthermore,
in the presentation of the results, the attention clearly glided toward groups
of statements and countable meaning units. The authors used for instance “Meta
Codes, Codes, and Representative Quotes” (p. 27) in a table with frequency
counts. This emphasis on frequency was also reflected through expressions such
as “. . . nearly every participant demonstrated . . .”
(p. 29), “most participants” (pp. 31, 33–34), and “The majority of . . .”
(pp. 24, 28).
Although the articles consider qualitative knowledge to be
something distinct from quantitative knowledge and their explicit ambition is
to capture singular experiences and processes, the results are presented in a
way that in a sense deconstructs these ambitions. The responses were collected,
studied, and ordered and similar statements were grouped, categorized, and
combined in such a way that the various singularities could be presented in
synthesized form, category by category. This occurs in a number of different
ways in the articles, for example, through classification into overarching
themes, through models/forms, and different methods of quantifying experiences
and statements. Because the articles focus on the frequency of a given
experience or process, they give the impression that the higher the frequency,
the more interesting the finding. The authors performed what can be understood
as a quantified weighting of the qualitative data. In fact, the articles never
draw attention to the participants’ experiences or the rehabilitation processes as unique. Rather, the singular experiences and processes gain value by not being unique, but representative of a larger group of participants.
In the process of capturing and presenting the unique
subjectivity of the participants, what is individual, unknown, and alien is
transformed into categories that pretend to be universally valid and
recognizable. The authors thereby risk marginalizing the essence of being different—that which does not allow itself to fit into
established systems of categories. While the studies explicitly analyze
experiences of being different, they marginalize the differences of being
different by only highlighting general characteristics of the feelings and
not their unique expressions.
By virtue of their stated qualitative research principles and
choice of qualitative methodology, the authors wish to capture and provide
space for singularity, subjectivity, and thereby difference. However, the
subjectivity and singularity that people with disabilities represent are
refined on the path toward scientifically created knowledge and “truth.”
Singularities that resemble other singularities tend to be considered more
important than the one that is unique. This seems paradoxically to create a singularity which subjects each one of the participants to
the weight of the aggregated uniqueness of the many (Foucault, 1971; Foucault
& Faubion, 2002).
One might claim that the young adults studied have been
segregated as scientific objects of study by virtue of what Kristeva described
as the deepest form of exclusion—They do not fit into the categories set
up by society (Kristeva, 2006). In this way, they are pushed
out—categorized as not fitting into the categories. Their exclusion is an
admission ticket to inclusion in research, which will study their path to
re-inclusion through rehabilitation. The young adults with disabilities are
studied as problems to be solved. The research categorizes their problems as
well as how these problems are experienced or appear to be solved by the
interventions. Their differentness is almost never regarded as a resource in
the selected studies. Rather their differentness is viewed as expressions of a
need for more support in terms of return to work rehabilitation (Hooson et al.,
2013), more involvement and coaching (Glavare et al., 2011) , more physical activity (Self et al., 2013), a need for increasing the patients’
ability to set rehabilitation goals, or the master-solution to almost any
challenge: more research (Draaistra et al., 2012; Todis &Glang, 2008).
To sum
up so fare, medical discourse is governed by a logic of steresis that classifies singular difference into
categories of difference characterized by a general lack. The only differences
that are visible to the medical eye are groups of differences, categories of
non-being (disabilities, pathologies) that can be clearly distinguished from
corresponding categories of full being, i.e. normality. This divide, this
categorization is what Kristeva refers to as the deepest form of exclusion. As
I have tried to show, medical knowledge is structured around these dividing
practices, around a machinery of categorization. This is the epistemological
face of the exclusion Kristeva is talking about. Medical knowledge is by definition
knowledge about categories, about groups of difference.
As shown, this does not mean that
there are not individualizing tendencies in evidence-based medicine. In many
ways EBM embraces the individual – but in a way that marginalizes
singularity. Individualizing knowledge practices such as patient involvement,
experience assessment and qualitative health research are undermined by an
attempt to make the singular difference fit with general categories of
difference. The one is reshaped in the image of the many (through standardized
measurement, patient education and management training) – and then
treated accordingly. The individual is conceived as an exemplar of a model
– as a general singular.
Kristeva
provides an alternative epistemology, an epistemology of the irreducible
singularity of being. With reference to Duns Scotus she claims that "truth is not in the universal idea,
nor in opaque matter, but in 'a this one', this man
here, this woman there". Instead of reducing those who are sick or
disabled to “objects under treatment” she builds her epistemology on the
emerging subject. And What is the subject?, she asks.
She answers: “That which in a man or woman remains open to a search for meaning
and sharing.” And as subjects in this sense, we are all essentially vulnerable,
according to Kristeva. We are all confronted with “the limits of life, with the
fear of deficiency and physical or psychic death,” Kristeva writes. She
therefore refutes the idea of an essential divide between those who are lacking
and we who are not. She insists that the experience of an essential lack, of a
non-being, is not something that distinguishes us that are in good health from
those who are disabled or sick. Rather, it is something that bounds us
together: “Not necessarily because “it
could happen to anyone,” but because it is already in me/ us: in our dreams,
our anxieties, our romantic and existential crises, in this lack of being that
invades us when our resistances crumble and our “interior castle” cracks.”
How can medicine incorporate an
epistemology of singularity and sharing, a conception of evidence and truth
that does not depart from a “universal idea”, a general category of difference,
but starts with “’this one', this man here, this woman there”? Is such a medicine
even possible? I believe that it is. And I believe that it has roots in evidence-based
medicine itself and in its excluded other.
One of the
most influential texts in the establishment of the paradigm of modern
evidence-based medicine is the book Effectiveness and Efficiency, written in 1972 by the
British epidemiologist who has given his name to the Cochrane Collaboration,
Archie Cochrane. This book is often referred to as the first sketch of what was
to become EBM: a celebration of RCTs as the gold standard of medical evidence.
However, this is at least partly a misreading of Cochrane’s text. Cochrane
draws a distinction in his text between two aspects of medicine: cure and care. Health care is supplying, he
insists, “on the one hand therapy, and on the other board lodging and tender,
loving, care.” He goes on stating that he will mainly focus on the cure aspect
out of practical reasons: ‘I have devoted most of the space to an analysis of
effectiveness and efficiency in the “cure” section, because so much more is
known about it’. He focuses on cure because he considers that at the
present stage more was known about it. Later proponents of EBM have interpreted
Cochrane’s practical delineation as a scientific demarcation: Cure is emphasized because more can (and
should) be known about it. Knowledge about cure can be based on groups,
categories of difference. Care is considered to be individual oriented and thus
falls outside the scope of medical evidence. This was not Cochrane’s intention.
Cochrane did not consider studies about the effectiveness of a cure as the only
legitimate form of medical knowledge. On the contrary, he considered cure and
care as equally important dimensions of medical knowledge though knowledge of
different kinds. While the first is group oriented, the second is individual
and value oriented, based on personal experience and a relationship to the
singular patient and his sufferings.
Still, to Cochrane, care is not
compassion for a lack of being as Kristeva warns us against. Rather, it is
driven by a democratic motivation and is profoundly linked to equality and
sharing. More than anything else care is about listening, listening to the
irreducible singularity of being. This is the concept of evidence that seems to
be lost within modern EBM: an evidence of proximity, of sharing; an evidence that listens.
By
recapitulating this double origin of EBM one might perhaps start building a
medical epistemology that embraces singularity. This does of course not imply
to refute generalized knowledge and thereby cause what Kristeva refers to as “a
perverted interpretation” denying the need for adequate diagnostics and
treatment. The point is rather that this knowledge must be supplemented and
constantly questioned by a second knowledge, a knowledge that acknowledges the
“incommensurable singularity of each person”.
Eivind
Engebretsen, University of Oslo
The Kristeva Circle
|
 |
 |
|---|