This is a letter written to the British Medical Journal in response to a just published review of cancer screening studies (Prasad, Lenzer, and Newman, 2016). The review concludes:
“ The harms of screening are certain, but the benefits in overall mortality are not. Declining screening may be a reasonable and prudent choice for many people.”
i.e. that there is little or no evidence that population cancer screening reduces overall mortality – the authors call for more honesty, bigger studies and more ‘shared decision making’ .
These are all strategies that still ignore the post Kantian insights (by Nietzsche, Heidegger, Adorno, etc etc) that our concept of the individual as ‘Enlightenment Man’ autonomous and free to make his own choices is a Myth (Habermas, 1982) and the scientific method ‘reason’ functions as a comfort blanket to orient us to a life without beginning or end – and that there is (to paraphrase Foucault cited in Esposito’s ‘Bíos’, from ‘Nietzsche Genealogy and History’) always an
‘interval that separates the origin from itself, or better, from that which is presupposed in it as perfectly conforming to its intimate essence’ (Habermas, 1982; Esposito, 2008) p79
However the review of the lack of impact of cancer screening is a very useful article and should be widely read. Now, in response, I want to draw attention to the mutual dependence of a relationship between politics, life itself, and the ethics of always necessarily sacrificing some lives in order to preserve others.
My comment here explores the ethics of screening and predictive diagnostics from a (up til now) neglected biopolitical perspective. It introduces an academic domain that up to now has had little inter-disciplinary overlap with Evidence Based Medicine. And although some of the language and concepts here may seem a little esoteric I would ask you to persevere. This concerns the domain of Biopolitics. Biopolitics explores the relation, and the effects of this relation, between the political order (ideologies if you like, increasingly neoliberal today) and Bíos, a term used by Esposito to describe a biological life that objectives itself and is subjugated to the political order (Esposito, 2008a, b).
Medical screening to measure the risks of, and to prevent, future ill health is an example of what the Italian philosopher Esposito, in his book Bíos, has identified as an immunitary mechanism that functions, at least ostensibly, in the name of ‘preserving life’. (Esposito 2008a) However this function, Esposito claims, is only secondary to its primary function, which is to act as a kind of biopolitical glue binding together, (maintaining and reproducing) the political order (today – neoliberalism) with a biological life of a subject (bíos) that is subjugated to and is an object for this political order. Biological Life’s ‘ecstatic fullness’ (Nietzsche), innate instability and ‘will to power’ (Nietzsche, 1986) over time and neoliberalism’s demand for economic growth lead to an ongoing intensification of these mechanisms. The paper by Prasad et al (Prasad, Lenzer, and Newman, 2016) is a very useful demonstration of the coincident sacrifice and destruction of life that can only increase as the immunitary mechanisms intensify. Esposito might claim (on the basis of his writings in Bíos) that only the development of a new ethical relationship to life itself by the medical profession and patients, that begins to refuses the sacrifice of one life for another, will slow this process down. In addition a fundamental shift from neoliberalism’s dominance over medical practice could at least re-orient the impact of politics on so-called patients’ ‘values’- values not at present generated by the individual but constituted by a subject subjugated by the political order.
As in this paper by Prasad et al (Prasad et al., 2016) the resistance to such destructive mechanisms focuses mostly on regulation, bigger studies, ‘more honesty’ and shared decision making (SDM). But we can see that these, alone, can and will never succeed in preventing an increasingly destructive (even thanatopolitical) process. These strategies may even function, given biopolitical politico-economic imperatives and power, to legitimate further intensifications in the longer run.
These resistive measures do not address the biopolitical and therefore the structurally neccessary ‘tremendous prophylactic’ (Nietzsche 1986) p113 immunitary drivers that maintains the subjugation of the population necessarily and reciprocally bound to and maintaining the existing social order and its socio-economic inequalities.
“….. against the vacuum of sense that opens at the heart of life that is ecstatically full of itself, the general process of immunization is triggered…. ‘the democratization of Europe is, it seems, a link in the chain of those tremendous prophylactic measures which are the conceptions of modern times.’” (Esposito, 2008a) p89, cites (Nietzsche, 1986) p113
Yes, medical practice, sometimes ethically, prevents suffering more or less in two ways a) the suffering today and b) preventing suffering tomorrow. But is it always ethical if it involves sacrificing one life for another, and when an individual does not know whether his body is being preserved or sacrificed or even both? Resistance to the excess of destruction is an important but biopolitical struggle. However the efforts by those resisting screening’s excesses focus on a struggle that is not seen for what it is. On the surface are the effects of systems using forms of biological knowledge in a struggle between a) interventions for profit and power, and b) non-intervention – sacrificing power and profit. But this is secondary to the primary biopolitical prophylactic (immunitary) imperative to ‘preserve life’ that results in the struggle between a) preserving an anticipated future life by eradicating risk, versus b) allowing a life today to take its chances and face risk, or if you like between preserving by sacrificing life or nor preserving life. Preventive screening and predictive medical interventions can either preserve life now or life in the future but either way must entail more or less sacrifice, destruction and weakening of life. New questions, language and strategies for medicine can emerges from Esposito’s writings such as: Is the intervention necessary? is it always ethical to weaken one life in order to strengthen another? Is it ethical to divide lives ‘worth living’ from ‘lives not worth living’ on economic grounds?
The French doctor and philosopher (and resistance activist fighting the Nazis) Canguilhem introduced the idea of ‘normative man, where life itself is its own norm; clearly not a panacea in itself but worth consideration:
“health is in no way a demand of the economic order that is to be weighed when legislating, but rather is the spontaneous unity of the conditions for the exercise of life.” (Esposito, 2008a) p189 citing Canguilhem ‘Une pédagogie de la guérison est-elle possible?’ In ‘Écrits sur la medicine’ (Paris editions, du Seuil, 2002, p89)
My final comment (not included in the letter to the BMJ) is a half formed problematic: if Man must have a Master, if Man can only change the object of his desire but not manage without one, then how can man become Canguilhem’s (and Goldstein’s) ‘normative’ man, where man creates his own norms? Perhaps a way forward might be to bridge a couple of gaps towards Annemarie Mol’s ‘Logic of Care’(Mol, 2006) – where the acquisitiveness and envious aggression of the Hobbesian individual is replaced by an object of desire that is precisely the natural expansiveness of the virtual ‘a’ life, and that requires a giving up of individual identity in favour of a collective ‘life’ that is trans-historical – so that the individual is just a temporary free-loader, on the bus of the life with no beginning or end for a little while, then just jumping off. Is there a political imperative here that rejects liberalism as that which coerces us into the constant state of war we are experiencing in the world today? Mol states:
“In the logic of care flesh and blood do not imply determinism. This is because, while knowledge from the natural sciences is mobilised in the consulting room, it is also given a new assignment. It is not asked to explain what the world is like, but asked to suggest what might be done. It is made to answer practical questions.” P43
However there is a problem here. We can see that the imperative to ‘do something’ must be a normative technique that silences the thought of the subjugated. In preventive medical terms one ends up saying: “I was just following orders” – leading to an Arendtian banality of evil (or even, to be speculative: a troop-like self-interested and self destructive banality of benevolence).
The question posed as ‘practical’ here has its roots in the semantic declension of ‘ethos’ from the Greek: the ‘nature spirit or culture of a society or community’. In this transformative declension ‘ethos’ becomes, today, what is determined as ethical by a juridical-political moral code that even determines the questions that should be asked and excludes those that shouldn’t. The (practical) question that ‘must’ be answered by the test of, or in the consultation about, preventive medicine hides what must not be asked for i.e. ‘an explanation’ for the question. It hides a modern bio-ethical ‘ordering’ (or normativisation) in the name of ‘preserving life’ which hides the immunitary mechanism that holds self-objectivised subjects in subjugation to the neoliberal political system and its inequalities (and orients us in a world of infinitude). But how? The mechanism works through the presupposition of responsibility and a guilt for harbouring an alien pathological ‘other’ ‘flesh’. Here, we can see there is a permanent infolding of the self in the form of multiple and ever present corporeal infestations.
This is the ultimately thanatopolitical immunitary semantic declension from ethos to ethics that is not solved by Mol’s ‘Logic of Care’ and requires the ethos of the self to be re examined.
Esposito, R. (2008) Bios: Biopolitics and Philosophy. Minneapoli: University of Minnesota.
Habermas, J. (1982) The Entwinement of Myth and Enlightenment: Re-Reading Dialectic of Enlightenment. New German Critique, 26: 16.
Mol, A. (2006) The Logic of Care – Health and the Problem o Patient Choice. Abingdon: Routledge.
Nietzsche, F.W. (1986) Human, All Too Human. A Book For Free Spirits. Cambridge: Cambridge University Press.
Prasad, V., Lenzer, J., & Newman, D. (2016) Why cancer screening has never been shown to “save lives”—and what we can do about it. BMJ, 352.