This is drawing upon a chapter in : ‘Being Time, Bíos’ By Kiarina Kordela
entitled : Aristotle’s discourses: chapter 9
She is linking Aristotle’s writings comparing and contrasting ‘household management’ and ‘the creation of profit’ with Marx’s analysis of capital, and in the end through Lacan’s psychoanalytical structure of discourse to the Hegelian-Marxist Master-Slave dialectic.
The could be titled: Health economics, capitalism and the crisis of EBM.
Or: Why every medical student should be taught Marx:
A key idea here is that risk has become calculable and Calculable-Risk e.g. is a potential avoidable future risk incurred if you do not consume a particular preventive medical intervention. Crucially it has both use and exchange value and acts as a surrogate coinage, or capital for the market.
Another key idea here is that the core of EBM should tackle this: the dependence of a capitalist EBM on the production of excess, surplus risk, surplus value.
‘Risk’ in capitalism functions as capital; it is manufactured not only for its ‘use’ (to produce any goods just sufficient to satisfy life’s necessities) – as in a ‘natural’ way; but also as an exchange value, where risk functions as capital, ie as an economic value that itself generates more surplus value (surplus profit, here defined as excess or surplus to needs) with each exchange. Risk does this as a surrogate for coinage by virtue of its status as a semantic value as well.
In other words, the market calculates the price of risk (eg in terms of a cost per QALY) which functions as a coinage of exchange value so that the market accumulates wealth through selling technology for Calculable-Risk (Cost per QALY) as a surrogate for Profit.
The selling of risk has a ‘use value’ potential , i.e. to reduce risk of future pathology or disease, but each sale generates ‘interest’ in terms of more value, surplus value over and above its ‘use’ value, in terms of its (semantic) meaning or value which is in part to coerce more purchase of more so-called risk-reduction technology. ‘Risk’ as capital can be thought of as the QALY (Quality of Life years) lost if for example you don’t buy/consume this new innovative technology; its opposite ‘Security’ is what you must spend money on in order to ‘enjoy’ the surplus value in the interest gained on existing risk ; this further capital is in its exchange value in the form of increased subjective precarity which now functions as capital for the next medical intervention, promising to add further surplus value, and this process is without limit. Risk is the coinage of exchange, capital, that increases in semantic and economic value through each cycle of exchange because it increases in semantic value through each cycle. Its use value is to reduce risk (promise a life extension), but its exchange value promises, paradoxically, more risk or precarity in the sense that life now seems riskier, requires even more security, security you will be prepared to pay more for. Every ratchet up in risk reduction technology ratchets up the desire to reduce risk further, the libidinal fear value of biological precarity, or ever more fearful and imminent mortality, the fear of death. Every ratchet up in fear technology thereby increases its economic value, its ability to garner surplus profit.
The NHS works as slave for the Master, the molecular diagnostics risk market; and personalized preventive intervention markets (Statins, Vaccines etc). The market takes pure economic profit at the expense of the NHS if the NHS replaces interventions with cost neutral interventions, so the NHS just works to produce more QALY (Quality of Life years) for the budget, creating surplus profit for the market. Risk reduction through exploitation of the body part and the patient consumer of the calculable risk puts the patient to work, who works in the illusion that the Master’s objective scientific knowledge, the ‘calculated risk’, is the ‘truth’ that guarantees or promises the fantasy of immortality, the limitless excess of life, the ‘surplus enjoyment’ of Lacan – in the capitalist Discourse of the University. The patient has a structure of discourse, his produce as a barred subject in an imaginary – his fantasy of a Master who knows, the knowledge he has to put to work, and the ?logic of scientific method, logos, with its circular logic, where effect produces its own cause – (like a diagnosis, even overdiagnosis the effect causes the presupposition that there was pathology that produced it originally, which is what makes it impossible to communicate overdiagnosis to a patient in a structure of discourse of the university – wedded to excess life or immortality.)
The crisis of EBM is the crisis of capitalism and relates particularly to (but not entirely to) the risks-markets. Preventive medicine or Precautionary Principle medicine.
This is why the core of EBM should be to question the truth of the available evidence not just to appraise it neutrally, the ‘evidence’ has economic and semantic values that function to produce excess, fantasy and a slave under the illusion of medicine’s mastery. The normalization of the use of calculable risk as a means of exchange to sell interventions for profit, puts risk on a homologous footing with calculable economic interest. It becomes normal to think of a risk as that which can be reduced without limit because it is normal to have no limits to the amount of profit that can be made when risk is calculable and equated to coinage. Where, as stated before, risk becomes symbolized by the loss of life that will be incurred if you do not buy the latest medical intervention, test or medication.
‘Belief’ in empirical evidence is founded in a belief in both the moral justice of the economic exploitation by capitalism – in Adam Smith’s invisible hand, and in Descartes God who produces the individual subject who believes in mathematised empirical logic as the ‘sole’ source of truth. Such faith leads to medical excess, surplus risk, as we are witnessing today.