The discourse of evidence-based healthcare (1992-2012) :power in dialogue, embodiment and emotion /

Abstract

The topic of this thesis is evidence-based healthcare, EBHC. The thesis has two key aims: to undertake an empirical exploration and analysis of debates around EBHC; and to develop a conceptual theorisation of these debates in terms of power. To fulfil the empirical aim I conduct a reading and analytic re-reading of EBHC-literature from the disciplines of medicine, physiotherapy and sociology. To fulfil the conceptual aim I draw upon the work of Foucault, Bakhtin and Barbalet to produce a ‘dialogical’ model of power. Treating debates around EBHC as ‘EB-discourse’, this thesis follows the tradition of discourse analysis; but breaks ground by deploying writing as a research method and applying ethnographic ideas to discursive study. This novel approach I call ‘literary ethnography’. Being a literary ethnography of EB-discourse, the thesis begins with a descriptive overview of the chosen disciplinary literatures. A methodological section explains the rationale for proceeding along the analytic path of dialogue; and then the thesis becomes gradually more analytical through progressively deeper readings of the same literatures. The thesis is structured into these three levels of review, methodology and analysis; and in each level, the three strands of literary context (medicine, physiotherapy and sociology) run in parallel as comparators for each other. EBHC began in medicine (as EBM), but following its course in other disciplines allows discursive similarities and differences to be explicated. The initially descriptive and gradually more analytical approach reveals the dialogical structure of the discourse, and discovers embodiment and emotion as ideas which, across all three contexts, trouble the terms of the discourse. The key findings of the thesis are that in EB-discourse, power operates through dialogue, by being split into different forms which interact to reinforce each other. Specifically, EB-discourse is built upon dialogical distinctions between mind and body, and between emotion and reason. These are dialogues which powerfully re-produce particular kinds of rationality. They are also in dialogue with each other; embodiment for the repressive aspects, and emotion for the productive aspects of power. The thesis also raises questions relating to the predicament of the patient in contemporary healthcare, and relating to the role of philosophical argumentation in social theory. It finishes with some suggestions for investigating the dialogical-power model in other areas of social life.