“In its pure form, fascism is the sum total of all irrational reactions of the average human character.”
(Mass Psychology of Fascism 1993 Wilhelm Reich)
Fascism is a hugely emotive term for good but also terrible reasons, but is it an appropriate term for aspects of Modern Medicine? Is there anything fascist about the practice of Modern Medicine? Does humanity have anything to fear from Modern Medicine? Might there be a good reason for using the term? Might using the term alert us to the nature of the powers of Modern Medicine, its objectives, strategies and mechanisms, and provide a rationale for resisting them.
Foucault said there was a crisis of anti-medicine, and that resistance is in a sense futile:
“On the other hand what appears to me to be much more interesting and which poses the real problem is what one might call positive iatrogenicity, rather than iatrogenicity: the harmful effects of medication due not to errors of diagnosis or the accidental ingestion of those substances, but to the action of medical practice itself, in so far as it has a rational basis. At present, the instruments that doctors and medicine in general have at their disposal cause certain effects, precisely because of their efficacy. Some of these effects are purely harmful and others are unable to be controlled, which leads the human species into a perilous area of history, into a field of probabilities and risks, the magnitude of which cannot be precisely measured.”
Let us imagine, for the moment; that the current Evidence Based Medicine strategies of combating overdiagnosis are failing, that no matter how transparent information is, no matter how much regulation there is, no matter how much the patient’s values are incorporated into decision making, that nonetheless over diagnosis and medicalisation will continue to grow.
Whose fault is it anyway? If a discursive formation, like for example the practice of Medicine as a social apparatus with all of its legal, political, economic and human/‘ethical’ inputs, interacting, sometimes mutually supportive sometimes mutually contradictory, if this formation has a strategy evident through the reality and concrete effectiveness of its practices, and these practices seem to be causing more harm than good, then whose fault is this? Does it become difficult to critique the formation because individuals who ‘believe’ in the ethical integrity of the ‘practice’ take it personally? This is probably so. But supposing it isn’t anybody’s fault? Supposing the strategies, objectives and mechanisms were outside of personal control, suppose the discursive formation has a life of its own , then what? Its not as if we can point to any one individual promising redemption, leading the way, no extreme political medical leaders mesmerising us all.
Do we need to take Medicine’s inherent contradictions more seriously. Although efforts to regulate the drug industry are important and may reduce the rate of growth of medical harm are they just a smokescreen for the underlying real problem? Let me just cite one apparently imponderable conundrum, a very important and vivid example. There are sharply polarised, indeed mutually contradictory and incompatible, views about the a) relative size benefits and harms of the UK breast cancer screening programme and b) whether it should continue in its present format if at all. The views are of people of great official esteem, Dames, Professors, all lined up against each other. Note, these views are just of shades of difference, they are mutually contradictory, they cannot both be right. Some countries are calling a halt to their breast cancer screening programmes, some like the UK are extending their programme to a wider age range. I don’t believe for one minute that the pro screeners are just in it because of vested interests, either in terms of reputation, power, recognition, status or money – those these can motivate any of us. It is highly likely that the opposing camps are both made up of sincere caring folk who believe what they are doing is in the best interests of the public at large. So how come the polarisation? And notice this is a polarisation that is scientifically based, people disagree about levels and natures of harm as well as possible benefits.
Baum (a now retired, well informed and highly esteemed professor of breast surgery and long time critic of universal breast screening, puzzled by the conflict) asked if something ‘ideological’ is going on?? I say: “Yes indeed it is!” , but, I suspect, not in the sense that he meant it. Using ideas based on Althusser and other French theorists of the 1960s and onwards, to be ideological is to be transformed as an individual into a subject of the ideology, into someone who believes fervently in what the ideology seems to promise, in one camp the ideology of ‘catch it early must be good’, in the other camp ‘first do do no harm’. This is uncomfortable reading because it does imply we have limited if any control over our beliefs. It is essentially quite anti-humanist and pessimistic. It may be ‘a process without subject’, but then again, after all, the human species is frightening.
Breast cancer screening is such a good example because of the visibility of its contradictions and non-senses. It is a good example of Modern Medicine’s huge struggle over the nature of technological representations of tissues that are on the borderline of normality (mammogram pictures, PET scans, biopsy samples under the microscope), a struggle that presupposes that there must always be a discernible normality-pathology distinction. But what is the power of this presupposition? If fascism is the use of power to persuade people to behave in ways that are not in their best long term interests and moreover to behave in ways that cause net harm to individuals – to be coerced into feeling willing to be harmfully treated then the pro-screening camps of Modern Medicine have some features of fascism. This is more coercion than nudge. The strong language is needed because it needs resisting, effectively.
Because EBM is stuck within the normality-pathology opposition and as a discursive formation believes that it is possibly to know the meaning of the borderline tissue representations brought forth by technology, then EBM, as it stands, is poorly placed to resist overdiagnosis. Its own internal hierarchies of evidence tend to be based on the apparently quantitatively measurable and therefore more valid, even the Qualitative methods make assumptions about the way people’s enunciations and actions should be interpreted. My argument is not with these internal hierarchies, for me all of the Science within EBM makes the same mistake which is that of assuming that all things can be known if we throw enough technology or interviews at it.
Both of the camps: pro and anti breast cancer screening, make the same mistake of assuming that scientific research will provide answers in a way that is independent of the ideology of the dominant Medical Formations (with their contradictory political economic and ethical inputs). Today the dominant ideology is ‘Catch it Early’ : The TV adverts say: “Have a health check, its easy and only takes a few minutes”. The anti-camp thinks the answer lies in a more objective appraisal of the evidence, the numbers.
Lacan’s seminar Science and Truth critiques the relation between Science and what he calls the post Descartes Subject-of-Medcine. Mis-recognition is the Truth of Medicine, it is the Truth that should provoke a crisis for Evidence Based Medicine. If there is truth here it is to acknowledge that for screening, the tests provide meaningless information much of the time, borderline changes are an unknown, they do not have any future that we can predict. Even, for the positivists, the most normal tissue in the world is constantly randomly mutating, cancers come and cancers regress. I’m not at all sure it is possible to resist the efforts of those determined to look harder and harder, more deeply into the molecular structures of our tissues, I don’t think it is. But I have very little faith in a model of Medicine that tackles the problem of overdiagnosis with the techniques and presuppositions that cause overdiagnosis in the first place. I think that the preventitive aspects of Modern Medicine, such as screening, have fascist qualities, I also think, following Reich and indeed Freud, that we all individually have fascist tendencies and this is part of our humans nature, our aggression, our insecurities. This explains why we are all susceptible to ideological manipulations by ideologies out of human control, this is why good people do dangerous things. I would say though let us continue to worry away at the aporia posed by the borderline, the lack of a gold standard as a foundation for test interpretation, the non-sense of ROC (test receiver operating characteristics) curves in these situations, even the normality-pathology opposition, and lets not be in denial about what we simply do not know.