Reductionism revisited


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a talk for the philosophy & ethics SIG 2011

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Reductionism revisited

  1. 1. Reductionism revisited<br />
  2. 2. Reductionism:<br /><ul><li>understanding the nature of complex things by reducing them tosimpler or more fundamental things
  3. 3. a philosophical position that a complex system is only the sum of its parts</li></ul><br />
  4. 4. “The night before I got married I tried to make a rational analysis, reasons for and reasons against......<br />....but it was a stupid exercise, because no equation of reasons could even begin to describe the situation. <br />How is love to be reduced to a series of propositions?<br />In truth, what binds people together – as a couple or as a society – always exceeds the reach of a purely rational analysis.”<br />Giles Fraser, Guardian, 30 April 2011<br />
  5. 5.  “capitalism ... wishes to pursue the maximum returns on its investment. To that end it exerts great pressure to turn human beings and nature into commodities.”The Observer, 24.4.11<br />
  6. 6. Reductionist developments have impoverished the mental health services.<br />Providing high quality care is reduced to meeting targets;<br />professionalism is reduced to competences;<br />diagnostic assessment is reduced to assessing needs and risk;<br />clinician-patient relationships are reduced to an assembly line model where functional teams provide ‘client-centred’ but fragmented and impersonal care.<br />
  7. 7. The current emphasis on health rather than illness, ... ‘recovery’ rather than treatments represents ‘magical thinking’ in attempts to deny the existence of ‘madness’ [chronic pain].<br />These manoeuvres also help to tidy away the suffering and emotional pain of the mentally ill person [chronic pain patient].<br />St John-Smith et al, RCPsych 2009<br />
  8. 8. LEAN, NICE, EBM, RCTs and research methodologies<br /> There is a good deal of criticism of evidence based medicine, which is suspected of being a tool not so much for medical science as for health managers <br />  Its main appeal is to health economists, policymakers and managers, to whom it appears useful for measuring performance and rationing resources.<br /><br />
  9. 9.
  10. 10. Lean is medicine for healthcare(no patients mentioned)Healthcare is full of committed, highly trained and motivated staff who struggle daily to work with broken, wasteful and disconnected systems and processes. Lean techniques have many of the solutions to sort out, repair and align these processes to organisational objectives. The solutions themselves come from within the teams working in the systems and processes.  <br /><br />
  11. 11.
  12. 12. LEAN, NICE, EBM, RCTs and research methodologies<br /> Instead of changing it, Lean unfortunately reinforced management in its current paradigm. <br /> As such it represents the further industrialisation of service, with effects that can only be deleterious.<br /><br />
  13. 13. LEAN, NICE, EBM, RCTs and research methodologies<br />focus on relationships in service organisations delivers levels of performance improvement that most people wouldn’t dare dream of – <br /> something far beyond the capacity of any commercial toolkit to deliver, even one that calls itself ‘lean’.<br />(Professor John Seddon)<br /><br />
  14. 14. LEAN, NICE, EBM, RCTs and research methodologies<br /> NICE works with experts ... as well as patients and carers. <br /> We make independent decisions in an open, transparent way, <br /> based on the best available evidence and including input from experts and interested parties.<br />(how is it obtained?)<br />
  15. 15. LEAN, NICE, EBM, RCTs and research methodologies<br /> NHS Evidence ... provides everyone ...access to a wealth of quality information and best practice <br /> so that every care decision made can be based on the best possible evidence. <br /> (how is it obtained?)<br /><br />
  16. 16. LEAN, NICE, EBM, RCTs and research methodologies<br /> The first step of EBM:<br /> translation of uncertainty to an answerable question<br /> the question should be phrased to facilitate searching for a precise answer.<br /><br />
  17. 17. LEAN, NICE, EBM, RCTs and research methodologies<br />EBM ‘not always RCT’<br /> But ‘ecological’ studies ranked 2c in hierarchy of evidence<br />
  18. 18. Quantitative research is generally made using scientific methods, which can include:developing instruments /methods for measurement.control and manipulation of variables.collection, modelling and analysis of empirical data.<br />
  19. 19. The null hypothesis, H0, is an essential part of any research design, and is always tested, even indirectly.<br />
  20. 20. Alternative terms for the traditional research paradigm are: quantitative, scientific, experimental, hard, reductionist, prescriptive, psychometric<br />
  21. 21. The traditional research paradigm relies on numerical (i.e. quantitative) data and mathematical or statistical treatment of that data. The 'truth' that is uncovered is thus grounded in mathematical logic.<br />
  22. 22. most of us are happy to accept uncritically simplified, reductionist, and blatantly incorrect statements so long as they contain at least one numberGreenhalgh, BMJ 1997<br />
  23. 23.
  24. 24. Qualitative research: aims to gather an in-depth understanding of human behaviour and the reasons that govern such behaviour.<br />
  25. 25. In qualitative research the possibility of the researcher taking a 'neutral' position is seen as more problematic.Qualitative researchers are exhorted to reflect on their role in the research process and make this clear in the analysis. <br />
  26. 26. a reductionist approach isolates variables and establishes relationships between them, qualitative methods examine how variables interact to become systems which cannot be completely understood from looking only at the sum of the parts.<br />
  27. 27. There is ample evidence that the legitimacy and usefulness of qualitative research is no longer questioned by most prominent scholars in administrative and organization science. (January 2011)<br />
  28. 28. Fig 1 Percentage of research in BMJ that is qualitative, 1994 to 3 September 2010.<br />Paley J , Lilford R BMJ 2011;342:bmj.d424<br />©2011 by British Medical Journal Publishing Group<br />
  29. 29. No mention of qualitative research methods<br />
  30. 30. Researchers who use qualitative methods seek a deeper truth. They attempt to make sense of, or interpret, phenomena in terms of the meanings people bring to them,adopting “a holistic perspective which preserves the complexities of human behaviour.”Greenhalgh, BMJ 1997<br />
  31. 31. Qualitative researchers aim to gather an in-depth understanding of human behaviour and the reasons that govern human behaviour.  Various aspects of behaviour could be based on deeply held values, personal perspectives, experiences and contextual circumstances.<br />
  32. 32. Here are a few important research questions in emergency medicine-Should we allow relatives to witness resuscitation?Are patients reassured by negative tests?What makes working in emergency medicine stressful?Are patients satisfied with the emergency care they receive?What is the effect of consultant shop-floor presence?<br />
  33. 33. These questions cannot be answered very satisfactorily by our familiar quantitative methods (counting and measuring). They require a deeper understanding of attitudes, experience and behaviour. We therefore need to use a different research methodology -QUALITATIVE RESEARCH.<br />
  34. 34.
  35. 35. Positivism and Reductionism<br />Positivism: <br />"the view that all true knowledge is scientific, and that all things are ultimately measurable.<br />"entities of one kind... are reducible to entities of another,”<br />"processes are reducible to physiological, physical or chemical events,“<br />"social processes are reducible to relationships between and actions of individuals,“<br />
  36. 36. Is there a philosophical difference between quantitative and qualitative research?<br />
  37. 37.
  38. 38. It is impossible, without further inquiry, to rely on what people say about themselves, their experience, or their interpretations of what has happened to them.Paley & Lilford, BMJ, 342: 30 April 2011the assumption being that there is a single verifiable truth<br />
  39. 39. Understanding the context in which people live is essential. Qualitative researchers need to identify their own contexts so that they understand how their own views and beliefs may influence the interactions they have with their participants.Kuper, Reeves & Levinson, BMJ 2008; 337:a288<br />
  40. 40. People understand the world differently, this informs their beliefs, attitudes, intentions and actions. Understanding these differences is sometimes a matter of listening rather than counting. Which is why history-taking is still important.<br />
  41. 41. positivists may argue that "if you can't measure it it's not worth studying"; their own problem is that if you can measure it, it's inevitably simplified and is therefore probably not "it".<br />
  42. 42. Conventional investigations do not reveal the cause of pain - diagnostic joint blocks and CT discography can provide a diagnosis: 15- 40% of patients have zygapophysial joint pain, 20% have sacroiliac joint pain>40% have internal disc disruption Management of chronic low back painNikolai BogdukMJA 2004; 180 (2): 79-83Reductionism in chronic pain – alive and kicking<br />
  43. 43. Fitness to work – a reductionist paradigm?<br /> Many clients with serious health conditions have been found fit for work, including those with multiple sclerosis, terminal cancer, bipolar disorder, severe depression, and agoraphobia.<br />BMJ 2011; 342<br />
  44. 44. The comfort of reductionism<br /> Certainty offers security<br /> The illusion of “absolute truth”<br /> The illusion that the right doctor will find the right answer (and thus a cure)<br /> One day we will know ‘it’ all and have all the answers.<br />
  45. 45. Divide each difficulty into as many parts as is feasible and necessary to resolve it.Rene Descartes<br />
  46. 46. The whole is more than the sum of its parts.Aristotle<br />
  47. 47. the love of complexity without reductionism makes art the love of complexity with reductionism makes scienceEdward O Wilson<br />