“Biological normality is an unenframeable and enframing social construct and a discursive practice that by being both mandatory and impossible engenders a crisis for the subject and categories of pathological tissue or madness or amorality that can be infinitely expanded and, as ‘flesh’, incessantly sacrificed and consumed as the hyper-precarious in debt ‘patient’ and ‘medical expert’ enjoy a consummation in the perverse sado-masochist torture chamber of unfettered capitalism.”
Owen Dempsey 2015
Just as geneticists no longer think of a gene as a ‘thing’ that determines traits but regards genomics as a much more complex process, in a similar way I think we should think of diagnosis not as an end in itself but as a process. This is a ‘process ontology’, (of the kind explored by continental philosphers such as Heidegger, Deleuze and Badiou), such that the process itself leads to new ways of Being. For geneticists epigenesis refers to the way the environment, including environmental changes due to behaviours, can intertact with the genome to influence our natures. For example studies suggest that smoking in adolescence may lead to an increased likelihood of obesity in the adolescent’s grandchildren. So too for diagnosis the process of diagnosis results in a new way of Being. In a way Marx’s historical materialism which suggests human abstractions and thought change over time in response to changes in social and economic environments is also a form of process ontology.
This is a challenge to the traditional notion of a diagnostic test, as exemplified by the Oxford Handbook of Clinical Diagnosis, which portrays a diagnosis as something you may have or are unlikely to have, something a ‘diagnostic test’ determines. This traditional notion sees the result of a screening test as ‘more of a presenting complaint’. This is harmful because it prevents us seeing the screening test as part of a very important diagnostic process. I think it is better to characterise all medical investigations as part of a diagnostic process and this includes elements of history taking and examination and even therapies.
What they all have in common is a differentiation of the subject between two or more different potentialities, “you probably will get ill, you probably won’t”, “you probably did have cystitis or you probably didn’t”, “you probably are anaemic or you probably aren’t” , “you probably should have a biopsy or you probably shouldn’t” – hence the name: dia-gnosis = ‘to know between’. It is of course possible to conceptualise, develop and use tests to achieve particular diagnostic functions, to achieve more or less certainty about the presence or absence of a present or future pathology or benefit or harms from further diagnosing.
The screeningtest performed by default, invitation or request for a ‘condition’ in an individual who does not have symptoms of that condition is also a medical test, and therefore part of a diagnostic process. It determines a difference between tissue or organism potentials. The screening medical test is of particular interest because it operates at the borderline, and exploring this borderline reveals some of the dynamics influencing the process ontology of overdiagnosis. (Where overdiagnosis is the result of medical testing that reveals a positive pathological potential that is exaggerated, wrong, false, and misleading and leads to further diagnostic processes of one sort or another.)
We ‘think’ the borderline representations of tissues or tissue biometrics from screening tests of diagnosis as the abstract ‘form’ of thought that is ‘pathology’ or the way we think about and value and imagine ‘pathology’ – an abstraction that by the nature of this abstract ‘form’ necessitates something that is ‘not-pathology’ and this is the impossible fantasy of a risk-free subject, also referred to as the ‘normal’. It is this borderline between an abstraction pathology and its imaginary demanded and impossible opposition ‘normal’ that is dynamic and shifts in response to advances in technology, always at the limit, posing unanswerable questions that demand to be answered.
As technology advances and new tissue representations and biometrics are produced such as genetic fingerprinting to predict cancer risk, so the nature of our subjectivity changes, as we are made more biologically insecure by being ‘securitized’ by diagnosis. This is a process ontology, an anthropological mutation that is creating a new way of Being for humans. The process is compounded and accelerated by three aspects of another process: neoliberalism in times of ‘austerity’, which: a) marketizes diagnostic processes for profit b) demands individual self-surveillance creating more biological insecurity and a subject-of-precarity and c) uses the rhetoric of austerity, debt and benefits to threaten and bribe to exclude marginal groups and enforce compliance with state or market diagnostic processes.
As well as market and bio-political processes to enforce secure citizenship, entitlement to benefits and temporary hoped for reassurance, diagnostic processes (such as the MammaPrint genetic fingerprinting test to estimate risk of recurrence after treatment for early breast cancer) involve a trade off between those that shall be spared unnecessary further diagnostic processes (eg not receiving chemotherapy after breast cancerbecause it won’t help) ) and those that may be excluded from receiving beneficial diagnostic processes (ie not receving chemotherapy after breast cancer when it would help). At a population level some are spared at the expense of the neglect of others. This requires a valuation of a cut-off point that is influenced by opposing pressures such as the need to penetrate the market by demonstrating cost savings, or to appeal to manufacturers of chemotherapy by maximising treatment levels , or to reassure doctors/patients averse to over treatments, or to reassure doctors/patients averse to undertreatments. These influences can account for the way diagnostic processes are researched and reported. The health insurers monitor claims for molecular diagnostics because of ‘indication creep’:the increasing use of tests outside of approved guidleine criteria suggesting that healthcare costs will increase even if a test is marketed in terms of reducing costs.
On a pessimistic note, surprise surprise, with the a) Transatlantic Trade and Investment Partnership (TTIP), b) the dismantling of the UK NHS under an ever more neoliberal state institution, and c) the hunger for the markets to form partnerships between medical managers of doctors, medical intelligence suppliers, therapy and diagnostic distributors, health insurance provison and coverage criteria, and medical diagnostic and therapy manufacturers (also known as theranostics and personalised medicine) – we are seeing, in the UK at least and probably globally, the tail of unfettered capitalism wagging the tail of the overdiagnosis doggie.