The InCEST Taboo for healthcare is how the use of a measure that threatens the market’s power to make surplus profits is essentially forbidden though much measured and regulated; it is the ‘Incremental Cost and Effectiveness Sacrifice Threshold‘ taboo – better known to health economists, and masquerading as, the ‘incremental cost effectiveness ratio threshold’.

This is a brief post that relates what is called the primitive ‘incest’ taboo to the way the USA has made it illegal to use cost-effectiveness data when deciding whether to purchase expense innovative medical technologies for the publicly funded health care services (Medicare or Medicaid in USA, and NHS in UK). The point here being to illustrate that decisions about healthcare funding are a) controlled by the market, b) rely on capitalism’s (need for) fantasies about the limitlessness potential for future surplus profits and immortality. The incest taboo, described by Levi Strauss the anthropologist, takes many forms but seems to have been universal among primitive tribes.  The philosopher Kordela in her book, ‘Being, Time, Bios‘ relates the incest taboo to man’s need for what she calls ‘surplus’ which in primitive times may have been in the form of spirits or later a monotheism. Today, in our capitalist mode, we have another form of God to worship, surplus as surplus value, or profit;  this fosters the illusion of immortality. In this short post I discuss how this manifests itself in the domination of the healthcare market at the expense of public health.

In the UK we have NICE (the National Institute for Clinical Excellence) which regularly agrees to purchase highly expensive technologies at the expense of of total population health. I find this quite shocking – it took me a while to comprehend that this is even true! What follows is a philosophical comparison between the reasons for our well known and trans-historical incest taboo, and the way the UK/USA are making any threshold for purchasing cost-effective healthcare taboo. As brief background: new interventions have a cost-effectiveness measure and this is compared to existing interventions. If the new intervention costs more per unit of health gain than the existing this is indicated by  the incremental cost effectiveness ratio (ICER). If this care is purchased the money must come out of existing care somewhere else in the health service.  But don’t worry too much about this as its not critical to the discussion.

Going back in history, man cannot make sense of a time without beginning, or an ‘origin’ – as a result,  the primitive incest taboo’s essential function is to ‘legalise’, formally if you like, that which is already a necessary impossibility – that is the impossibiity of being able to ‘make sense’ of being human through a solely self referential mode of being, in the face of the unavoidable non-sense of the problem of ‘origin’. Incest is a self-referential activity, at the very least, in terms of reproducing your own genes.Simply put, if you can only refer to yourself as the source of knowledge you’ll never be able to make sense of it all. So incest becomes taboo, a taboo legitimised by a Law, a Law according to a faith in something transcendental, a God of some kind, something man cannot physically experience but only imagine.  We ‘need’ a reliable guarantor of ‘the truth’. (The question of the origin of man and the taboo is another interesting philosophic detour full of mind bending paradoxes so we can leave that to one side for now – see Kordela if interested)

So, to make sense of the non-sense of origin (infinity, time, mortality) we turn to fantasy. We must have faith in an Other we can refer to instead of being self referential – and the function of the Other is to provide a phantasmatic basis that enable us to make a kind of sense of the problem of ‘origin’. Or, if you like, that enables us to disavow the reality of the non-sense of the problem ‘as if’ life makes sense, really.

The InCEST taboo – (‘Incremental Cost and Effectiveness Sacrifice Threshold‘ taboo) performs the same function for healthcare in capitalism – it prevents the contradiction inherent in the self/referential effects of sacrificing surplus economic value in order to maintain population health OR making surplus economic value whilst sacrificing population health, both of which undermine the sense making effects of the illusion of fantasy of economic growth or immortality respectively. This would result in the loss of the ‘surplus’ of capitalism and would therefore force a self-referentiality crisis. The loss of the capitalist fantasy ‘Other’. This would result in a non-sense that would require an alternative ‘Other’, or a renewal or reinforcement of the taboo to re establish faith in capitalism’s ‘surplus’.

In brief, very expensive high-end technologies such as genetically based molecular diagnostic tests, or cancer treatments, are being funded by the NHS even though they will result in a need for health trusts, already under great fincancial pressures, to disinvest in highly valuable servces such as mental health services, thereby leading to a deterioration in population health.  This is being done, in the name of preserving innovation, and business, or to provide treatment for special cases, with lobbying from special pleaders, e.g. for childhood cancers, withough identifying who is going to have their care withdrawn as a result.  The InCEST taboo ensures this can continue, surplus profits continue, the fantasy of immortality continues, but the healthcare available for the public deteriorates. The InCEST taboo will also become evident if the transatlantic trade and investment partnership between the US and Europe becomes law, when e.g. American business will be able to sue the UK if it fails to ensure that it can make its profits, unimpeded by worries about public health,  and penetrate our NHS markets.  The end of the NHS is nigh.