Shared Decision Making and Overdiagnosis as Illusory Developmental Psychologisation

” …Additionally, the suggestions from some women that overdiagnosis would be relevant to their decisions only if they were actually diagnosed with a screen detected cancer reveal a concerning misconception that a screening mammogram is a separable event from the cascade of investigation and intervention that may be triggered by an abnormal result. This highlights the need to explain clearly to women that once cancer is detected, evidence based treatment is virtually always indicated because potentially threatening cases cannot be differentiated from those representing over diagnosis.” Women’s views on overdiagnosis in breast cancer screening: a qualitative study  Hersch J e al BMJ 2013;346:f158

This quote is from a paper looking at women’s reactions to being told about the possibility of over-diagnosis from breast cancer screening, and how it might influence their decision about whether to be screened. Notice how, not always, but often, that knowing about over diagnosis did not dissuade from a decision to be tested, but that the women then thought that they could use that information to make a decision about whether to have treatment if tested positive. The comment about ‘ … making it clear that once diagnosed treatment is virtually always indicated’, suggests this attitude of the women doesn’t meet with the approval of the researchers who, despite the possibility of over-diagnosis, would seem to ‘insist’ on compliance with treatment.

How does this narrative fit with a Lacanian structure for discourse and subjectivity? Is there a suggestion here that some signifiers are being rendered meaningless and repressed into the unconscious?

“The temporal relation between past and present is something that is constructed and reconstructed by the subject in ways that will defeat any developmental account that tries to define how particular events in the past will have psychological sequelae. “Psychology After Lacan by I Parker 2015 p 21

“What is realised in my history is not the past definite of what was, since it is no more, or even the present perfect of what has been in what I am, but the future anterior of what I shall have been for what I am in the process of becoming.” (Lacan cited in Parker, 1956/1977b:86 – The Seminar of Jacques Lacan: The Four Fundamental Concepts of Psychoanalysis)

EBM’s and NICE’s shared decision making discourse can be conceptualised as a kind of developmental psychologisation of the ‘client’ and clinician. The normative idea is that information can be presented as ‘full’ – leading to a subsequent fully informed decision. There is discourse of a process by which the client ‘develops’ as a fully self aware subject, into a more knowledgeable client, able to, as is well known, ‘make the right choice for them’, implicitly responsibilisng the client, and justifying the testing process.

If I ‘shall have been over-diagnosed’, but the test promises surplus life then  how can I make sense of contemplating the test?

But for Lacan – each moment of action recreates subjectivity anew not dependent in a linear way on what has gone before because of the necessity for sense making and the role of the unconscious – for example: to be told about overdiagnosis and then told to decide about a test means that the client has to imagine how he shall have been overdiagnosed (a future anterior tense) – thrust into a relationship of equivalent use value of outcome with the use value of the test, with the full glare of its accuracy and inaccuracy laid bare, but in capitalist healthcare such a certainty about equivalence is a certainty about mortality and is in effect forbidden in order to to sustain the sense of the offer of the test underpinned by state/scientific/medical authority, and the test as a commodity in a capitalist economy that promises surplus semantic and economic value. So even though fully informed in the past, the action is to have the test anyway and if positive to presume it is a true positive because the future anterior possibility of dying is repressed into the unconscious in the process of becoming (a compliant patient)

Mapping onto Lacan’s structure of discourse

In this diagram we can map this narrative onto the University discourse structure. Here S2 is the ‘all knowing’ NICE diktat, result of the so called ‘independent review’ that concluded screening is ‘good’. S1 is the screening test itself as authentic and as always providing a true result,  it is the ‘truth’ that drives S2. ‘a’ is a subversive-impact factor imposed on the discomfort the client feels when told about over-diagnosis, or at least suspects the test’s threat to life. There is a necessary repression of the idea of over-diagnosis into the unconscious, and this takes place in the ‘work’ or ‘clinical labor’ to coin Wallaby’s phrase, to create a subject $, that believes in the fantasy of the perfect test and therefore complies. The researchers insistence on treatment if the test is positive sustains the fantasy of the test result as always perfect and requires the clinician’s repression of over diagnosis post hoc as well.

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