Examining Evidence in RHM

Rhetoric of Health & Medicine

Vol. 4, No. 3, pp. 275–287

J. Blake Scott, Cathryn Molloy, and Lisa Melonçon

In our editors’ introduction to the 4.1 issue (Molloy, Scott, & Melonçon, 2021), we documented what we read as an exigent moment for “contemplating a turn in RHM (the field and community) and in RHM” as we transition “from a fledgling field to a recognized field” (p. iii). We propose here that part of meditating on that turn is critically examining how evidence functions (and might function) for us—particularly as we address issues of equity, diversity, and inclusion in a field that is transdisciplinary and settling into some predictable, albeit fluid, rhythms. A ubiquitous term, evidence is also a highly involved and contestable one, both for RHM and for the practices we study.

Take, for example, the relatively recent phenomenon of evidence-based medicine (EBM), first developed in medical education as an approach for improving clinical decision-making about individual patients (Evidence-Based, 1992). Even as the uses and reach of EBM have expanded and taken hold (see Lambert, 2006), it has become more contested—e.g., around incommensurability of population evidence and individual patient cases, de-emphasis on patient narratives, sidelining of clinical intuition and judgment (see Goldman & Shih, 2011). Despite, or perhaps because of, this contestation, the concept of evidence has become both more consequential and “underanalyzed” (Martini, 2021). In Bounding Biomedicine, Colleen Derkatch (2016) called contestations over “methodology in EBM‐oriented research on complementary and alternative medicine (CAM)” a “fundamentally rhetorical problem” (p. 371). Addressing the rhetorical nature of evidence and the fact that it is underanalyzed, rhetoricians of health and medicine have examined the meanings of evidence more broadly. For example, RHM scholars have asked prior questions about producing evidence in medical research (e.g., Teston, 2017); diagnostic processes and care standards (e.g., Graham, 2015); governmental nutritional guidelines (e.g. Hite & Carter, 2019); clinical trials (e.g., Barton & Marback, 2019); and patient decision-making (e.g., Pender & Covington, 2020). In a forthcoming RHM piece on standardized patient programs (SPPs), Sara Press points to high stakes and political functions of evidence-based health practices and their rhetorics, explaining how their reliance on standardization can treat “knowledge and patients in reductive and often hierarchical ways, … shroud sociopolitical biases, and disadvantage marginalized individuals” (n.p.). We would add that demarcating what counts as evidence, determining how to generate and present it, and arguing for how to value and act on it are also thoroughly ethical problems requiring us to ask critical questions about our goals, values, methodologies, boundaries, and identities as RHM scholars.

A more immediate exigence for raising critical questions about how RHM treats evidence is shaped, in part, by heightened concerns about the roles evidence plays in the COVID-19 pandemic. A recent editorial in the British Journal of Medicine, for example, warned that “time pressures, inadequate research infrastructure,” and other factors of COVID-19 research threaten to exacerbate problems of “poor questions, poor study design, inefficiency of regulation and conduct, and non or poor reporting of results,” and also pointed to the problem of poorly reported reprints (Glasziou et al., 2020, p. 1).1 A pressing (though not new) evidentiary issue with COVID-19 research is likewise the representation of subpopulations in vaccine trials, including the underrepresentation of Black communities that make up a disproportionately high percentage of COVID-19 deaths. One of the rhetorical dimensions of this problem, of course, is building trust with communities that have been subjected to racist medical research. Beyond the sphere of medical research, the ongoing pandemic has enabled a confusing and sometimes dangerous proliferation of evidence—sometimes referred to as an “infodemic”—that includes misinformation and unique forms of evidence-making and valuation around conspiracy theories (see Rice, 2020). As is clear from the past year, “evidence” invoked in the service of erroneous health claims related to COVID-19 pandemic can move institutions, publics, and individuals to make decisions that run counter to public health goals. An example that brings RHM into important scientific conversations and raised critical questions about the rhetorical functions and effects can be found around the proliferation of erroneous scientific evidence (Randall et al., 2021). As reported in Wired (Molteni, 2021), a network of researchers, including RHM scholar Katherine Randall, uncovered that the scientific community had been relying on a measure—5 microns—that turned out to be a faulty measure to determine airborne transmission and, consequently, public health guidelines about distancing.

Although RHM scholars have raised critical questions about how evidence works in the practices we study, we have been less inclined, we submit, to turn such critical questions on ourselves and our own evidence-assembling practices, at least prepensely. Sure, we have engaged one another’s arguments from evidence in spaces like the RHM Symposium, and RHM reviewers have evaluated the evidence presented in manuscripts and made recommendations about ways to strengthen it and its presentation. Like the journal’s reviewers, we as RHM co-editors have often encouraged authors to unpack and explain the methodologies they used to generate evidence, to consider additional forms of evidence (including experiential knowledge) that could inform their studies, and to further qualify their claims based on the available evidence. But, as a field, we could more fully examine and discuss how we conceptualize and use evidence. For example, in our attempt in the “Manifesting Methodologies” introduction to identify RHM’s characteristic qualities and contributions, two of us did not directly mention the field’s processes for manifesting and treating evidence. We suspect that part of what we’re reading as the field’s reluctance to examine evidence-assembling can be attributed to rhetorical skepticism of “obviousness” or “proof,” in the sense of showing something to be true—both parts of the term’s etymology. Of course, as rhetoricians, we deal in the realm of possibility and probability and, as such, we take “proof” to be more of an appeal than a guarantee of certainty, just as we recognize discourse as dynamic mediation and sanctioned provocation. In this way, our dispositions on evidence align better with another earlier definition of the term that allows for less rigidity, from Old French c. 1300—the “appearance from which inferences may be drawn” (Online, n.d.).

Why is a critical attention to evidence important to RHM? First, it can help us self-reflectively experiment with and make better decisions about our methodologies, guided by an ethical attunement to the phenomena we engage and what we are noticing and generating from this engagement. This is part of what Blake and Lisa (2018) were getting at through the term “methodological mutability” (p. 5). For example, in her study of the “emplaced rhetoric” of a hospital chapel, Jennifer Edwell’s (2018) questions about how to “demarcate the boundary of the experiential landscape” and the “phenomenological evidence” she gathered were guided by an ethical commitment to respect the privacy of chapel visitors who could be experiencing anxiety, pain, or grief (pp. 165–166). Elizabeth Angeli and Lillian Campbell (2017) asked critical questions about the experiential and intuitive evidence healthcare workers draw upon to inform their decision-making, and though this exploration also raised questions about and developed new strategies for documenting “intuitive action,” particularly through a taxonomy of intuitive cues (environmental/bodily, technological, interrelational, and internal). Similarly, Heidi Lawrence (2020) looked beyond standard evidence for why people are skeptical of vaccines to identify what she calls their “material exigencies,” including shared concerns about risk and uncertainty; in doing so, she opened up for those seeking to address vaccine hesitancy more attuned, respectful, and promising forms of engagement and persuasion. These examples point to the productive inventiveness that our attention to evidence and evidence-assembling methods can make possible.

Second, a critical attention to our own evidence-assembling practices can help us to articulate the value of rhetorical scholarship (useful or applied) to other stakeholders. Here, again, we can relate our challenge to that of EBM. As Andrew Van de Ven and Margaret Schomaker (2018) argued, the adoption of EBM-based healthcare practices depended on the ability to persuade disparate stakeholders of the desirability of altering practice in light of accumulated evidence. We see RHM as situated similarly—interested in how new knowledge is created and valued in the wide expanses of healthcare delivery as well as in the everyday, embodied experiences of health subjects. Our RHM stance toward evidence has been characterized by an openness to accepting the widest range of possibilities so long as it is shaped by rhetorically inflected methodologies and contributes to “nuanced observations about how persuasion works (or could/should work) in discourse and practice” (RHM Focus and Scope), and as long as authors make arguments about it rather than assume its obviousness or “proof” (in the sense of certainty) of something. RHM, thus, approaches knowledge and evidence as rhetorically situated and assembled, partial, conditional, and contestable (see Haraway, 1988). Often, RHM calls on more contextual information and more attunement to the complexities of rhetorical knowledge-making, as in Judy Segal’s (2009) suggestion in relation to online health information that there can be deeper information to gain from asking prior “what” and “why” questions rather than working from a given starting point and proceeding with “how” questions (Segal, 2009, p. 359).2 That is, rhetorical lenses can make space for full-bodied inquiries that push the gathering and parsing of evidence out of routinized procedures (or, as Pender [2018] puts it, “habitual grooves” [p. 141]) and into more reflective, impressionistic, and creative ones.

As a field, we have increasingly engaged various types of embodied and phenomenological evidence, as well as qualitative and quantitative evidence (even big data) from empirical research. That said, we don’t take these forms of data as offering proof in and of themselves; we call on authors to provide persuasive interpretation and justification of not only the evidence, but also of the processes that assembled or produced it. Likewise, and fitting with this larger acceptance of evidence as fluid, we, like other fields, see autoethnography and narrative as potentially providing valuable experiential evidence if such accounts are compellingly drawn and defended. Our focus at RHM on methodological rigor, then, is less about ensuring adherence to predetermined notions of what counts as valid evidence than it is about questioning what seems obvious or apparent in favor of thoroughly descriptive, explained, and reflective accounts of how authors develop and marshal data, enthymemes, and other elements of arguments to ground or support a claim—a practice that values contextualization, admits partiality, and allows for quite a range of methods. We ask authors to pull the curtain back on their processes of creating new knowledge out of specific evidence in ways that would allow emerging researchers to learn how to adapt methods and methodologies creatively, and how to select, curate, and arrange evidence innovatively for their own projects. When we review manuscripts, we want to know what constituted authors’ “data” (where relevant) and where they are seeing signs of the phenomenon they are bringing to readers’ attention. We also, in a highly practical sense, want readers to get a full sense of what the author did and why they made particular choices so that they can make an informed evaluation of the argument’s evidentiary persuasiveness.

Derkatch (2016) observed that “Evidence reflects the character and limits of the communities that produced it” (p. 29). This observation points to another reason for critically questioning our own evidence-assembling practices—doing so can help us build and extend RHM as a robust, inclusive, and widely informed dwelling place. Just as they do in other fields of study, notions of evidence do a great deal of boundary work in RHM. As such, the ways we engage evidence demarcates the shifting contours of the field—especially the blurred boundaries between RHM and other fields of study. In this respect, evidence intersects with ideas of who is welcomed to participate in the field’s scholarly practices (as authors, reviewers, editors, etc.), how and for whom scholarship is situated, and what forms of scholarship are legitimated and valued as generative. And critically engaging these ideas can bring issues of diversity, inclusion, and equity to the forefront.

The editors’ introduction to the inaugural issue of this journal foregrounded our goal to build a dwelling place where a growing and diverse network of scholars engaged in RHM work would engage “through edifying discourse” (ix). The idea of a dwelling place, Blake and Lisa (2018) pointed out, suggests “an intimacy, a familiarity, a sense of comfort” (ix). That position of comfort was a necessary condition for a dispersed field of study to start to gather; it was the kind of dwelling place that allowed for the field to get to where it is now. As Aja Martinez (2018) reminded us, though, the constitutive parts of centralized privilege in academic spaces are the “the rights to space” and the “assertion of comfort in said spaces” (p. 223). As RHM continues to move into predictable rhythms in its generation, valuation, and use of evidence, we must continue to question and trouble any privilege created through the journal’s (and field’s) dwelling space, in part by critically re-imagining this space and its boundaries in increasingly diverse and inclusive directions. By building stronger connections with other spaces—other nodes from which our own field draws energy, inspiration, and legitimacy—we can more expansively constitute our field through diverse scholars and stakeholders working in multiple rhetorical haunts, especially in ways that open up the less familiar and the productively uncomfortable.

In their provocative and thoughtful editorial in Frontiers in Communication, critical health communication (CHC) scholars Shaunak Sastry, Heather Zoller, and Ambar Basu (2021) lament the “diffusion” of work in their area and how this has contributed to this work being under-engaged by other “scholarly collectives” such as RHM, who could benefit from their work “blending culture-centered analysis, abductive analysis, and critical reflexivity,” among other contributions. Their lament rings familiar, as RHM’s rapid growth and addition of dedicated forums obscures the fact that, for decades, the efforts of scholars using the full and diverse spectrum of rhetorical theories and concepts to examine health and medical phenomena were diffuse and hard to recognize. Indeed, “rhetoric of health and medicine” is a relatively recent coinage meant to address this problem of recognition. But we also read Sastry, Zoller, and Basu’s imploration as a reminder to continue, and to even more earnestly engage the work of related scholars and other stakeholders. We’ve done some of this through our development work and open calls for special issues and sections. But such efforts should expand to engage, invite, and welcome additional related but underrepresented scholarship, such as work framed by anti-racist, decolonial, and transgender rhetorics, and rhetorical work that targets health inequities and recognizes other oppressive practices (e.g., racist law enforcement, deportation and border policing, domestic abuse, human trafficking, environmental plunder, linguistic imperialism, hate crimes, educational malpractices, and many more) squarely as health or medical issues. For RHM, this will require, among other things, more targeted manuscript development work, looking for ways to diversify leadership and involvement in the journal’s (and Symposium’s) operations (in part through mutual mentoring), and continuing to expand our pool of reviewers while also encouraging them to recognize the value of reinflecting RHM through additional lines of inquiry, rhetorical concepts and approaches, and forms of evidence.

The dynamic field of RHM, as we articulate above, is an amalgam that has always straddled the social scientific disciples and the humanistic ones, and, thus, we owe a significant debt to a wide range of areas for opening space for the hybrid work we do. The transdisciplinary and hybrid nature of our field makes “evidence” a grey and squishy term for us, but it also positions us to productively synthesize, adapt, and invent evidence-shaping practices that also tacitly critique exclusionary epistemological claims.

As we resist settling into overly predicable rhythms, we might move beyond the articulation of diverse methodologies and their assemblages of wide-ranging evidence, to also ensure the inclusion of scholarly threads that have enabled us to do this work and that will enable a broader, different, but still identifiable “us” to dwell and flourish together. To do this, we have to pry open and leave available for (self) critique our values and processes for “legitimating” evidence (not unlike how some in our field have critiqued the processes and effects of medicalization). In her reinflection of “dwelling spaces” through movement, Terese Guinsatao Monberg (2011) drew on anthropologist Martin Manalansan to emphasize that “movement is not always about traveling or crossing borders,” a recognition that can help us pay more attention to how our evidence-legitimating practices can restrict imaginative and inclusive movement within our assumed borders as well as across them (pp. 27–28). Monberg suggested that a focus on dwelling can involve “the kinds of movements and ‘moments of immobility’ that occur within communities/places—and how these im/mobilities illustrate the collage of differences within a place or community” (p. 28). Taking this recognition to heart, we propose that RHM ask (a)new questions about evidence, including (but hardly limited to) to the following:

• How has “evidence” been defined and operationalized in RHM scholarship? What assumptions about knowledge-making inform these definitions, and what other types of rhetorical proofs, patterns, and perspectives might we consider?

• How can we treat evidence in ways that productively trouble and reimagine it?

• What processes and criteria have RHM used to legitimate evidence, and how can we make these more apparent and open them up to contestation?

• What are the roles of experience and intuition, inference, and speculation in evidence?

• What does the evidence we recognize and assemble suggest about our methodologies and their affordances and limitations?

• What are the stakes of standardizing or normalizing forms of evidence to include how that evidence is presented?

• For whom does the evidence we recognize or assemble matter, or count? And, in what ways can RHM advance more diverse and inclusive forms of knowledge-making within and across our boundaries?

• What can fragments, gaps, or silences be evidence of? What might such gaps or silences suggest about us and our practices?

Introduction of Articles in this Issue

We open this issue with a rhetorical history by Erin Gangstad, who examines the National Tuberculosis Association’s practice of selling Christmas Seals (from 1920 to 1968) to raise funds through which to support tuberculosis research. Her essay analyzes how these Christmas Seals shaped popular culture representations of tuberculosis in their use of imagery meant to convey health, whiteness, and holiday settings. Focusing on the power of popular, non-expert images—especially in medical charities—she argues that such depictions functioned to distance viewers from the realities of disease and to play into audience’s hopes for a world free of tuberculosis. In light of our emphasis on evidence, we want to call attention to Gangstad’s use of visual artifacts as a reminder that evidence comes in many forms and often requires multiple interpretations.

Our next research article is Hillary Ash’s case study of the Center for Disease Control and Prevention’s (CDC) early AIDS surveillance definitions with the aim of demonstrating how women were overlooked in data reporting in the epidemic’s first decade. Framing this failure in rhetorical terms, Ash shows how operational definitions of the topoi of space, time, correlation, and causation were limited. Arguing that more inclusive approaches were possible within the CDC’s surveillance infrastructure, she suggests that these topoi may offer a unique configuration for unpacking surveillance definitions in syndromes like AIDS and that rhetoricians may use a rhetorical understanding of topoi and their possibilities to explore other diseases surveilled by the CDC. Ash’s article brings into focus the disciplinary move of using rhetoric’s own infrastructure (topoi in this case) as an evidentiary tactic to better understand a phenomenon (surveillance).

This issue also contains three persuasions briefs, which is a genre of submission that is unique in communication and writing studies. The persuasion brief is meant to “explain the role of rhetoric in and synthesize rhetorical insights about a particular set of health or medical practices.” Persuasion briefs can port evidence differently than research articles, giving authors more leeway with how and for whom they build their arguments and marshal evidence.

Kelly Pender’s persuasion brief examines the controversial procedure of contralateral prophylactic mastectomy (CPM). Showing how researchers and journalists typically attribute increased use of CPM to patient misunderstanding of breast cancer risk and, therefore, focus on improved patient education as a way to mitigate this overuse, Pender demonstrates the ineffectiveness of increased patient education and argues that the overtreatment of women that makes CPM an effective, if unconventional, treatment choice. Her critique hinges on the insight that risk is something that patients do and not merely something they know, which puts evidence into action in ways not totally expected.

Next, Krista Hoffmann-Longtin and Kelsey Binion provide evidence that invitational rhetoric could do important work in providing a communicative lens for partners and providers contemplating vasectomy in the context of the procedure’s underutilization in the U.S. despite its safety, efficacy, and affordability. Hoffman-Longtin and Binion’s persuasion brief acknowledges that invitational rhetoric alone cannot alter the narrative about vasectomies in the U.S., but it can be a step in the right direction toward more informed decisions based upon specific circumstances.

Our third persuasion brief is by Michael R. Kearney, who takes on evidence by providing readers an examination of the limited applications of Charles Sanders Peirce’s use of abduction in clinical decision-making. Merging research of patient noncompliance and clinical inertia, Kearney makes a case for evidence in the language of abductive reasoning itself. Through his close reading of American doctor-turned-novelist Walker Percy’s theory of triadic communication, Kearney posits opportunities for learning, growth, and development of RHM perspectives via examining such sites of uncertainty.

Finally, this issue includes three book reviews that show the range of topics and evidence in RHM-related publications. The first is Calvin Coker’s review of Amy Koerber’s (2018) From Hysteria to Hormones: A Rhetorical History—a text that he assures readers examines past phenomena with “urgency in the present,” and a book that underscores the troublesome nature of evidence as it moves between disciplines, practitioners, and patients. The second is a review of Bethany L. Johnson and Margaret M. Quinlan’s You’re Doing It Wrong!: Mothering, Media, and Medical Expertise. As Rachel Lussos explains, this book “redefine[s] expertise as dynamic, using the example of advice given and received during the life cycle of early motherhood,” which again takes up issues of evidence as it intersects with issues of expertise. The final book review identifies a new scholarly form of evidence as Shannon Fanning explains in her review of Cristina Hanganu-Bresch and Carol Berkenkotter’s Diagnosing Madness: The Discursive Construction of the Psychiatric Patient, 1850–1920. Fanning highlights the way that Hanganu-Bresch and Berkenkotter bring together a wide variety of archival materials to create “institutional genre suites, collections of texts that include admission notes, certificates, and other textual traces that apply to the patient’s life before, during, and after their time in psychiatric facilities.” These three books and their reviews collectively bring into sharp focus RHM’s engagement with diverse approaches to what evidence means.

With these works, this third issue of volume four continues the call for critical reflexivity into the practices of RHM via a specific focus on evidence. Ultimately, we hope this issue of RHM challenges us—editors, reviewers, authors, teachers, students—to continuously question the ways we do our work and the key assumptions built into the terms—such as evidence—that we rely on.

References

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1 It follows that physicians, public health officials, and others have faced additional challenges in evaluating and synthesizing evidence and developing clinical and public health guidelines from emerging COVID-19 research. As reported by Science news editor Jeffrey Brainard (2020), scientists evaluating systematic reviews of COVID-19 research “are grappling with a pressing question: In the push for quick answers, have pandemic-related evaluations of studies sacrificed thoroughness and rigor?” (n.p.). Researchers have responded by updating “living reviews,” coordinating evaluation and evidence synthesis efforts, and creating “narrative reviews” through a qualitative approach (the latter necessary for “guidance and policy for behavioral measures against COVID-19”) (Brainard 2020, n.p.).

2 Similarly, feminist rhetorical practices, as discussed by Jacqueline Jones Royster and Gesa E. Kirsch (2012), involve “critical imagination,” or questioning what counts as evidence and reconfiguring interpretive frameworks (p. 20), and “strategic contemplation,” or resisting “rushing to judgment” around “neat resolutions” based on received evidence (p. 22). We echo Malea Powell and other members of The Cultural Rhetorics Theory Lab (2014) in noting that strategic contemplation calls us “to consider the space our intellectual work creates, where space is understood as a real, lived entity, with consequences and impact on all kinds of people and other spaces, both present and past, and future” (n.p.).