Author: Owen Dempsey

Chest Physician Aberdeen with a special interest in asthma. I have a private clinic and website. Apart from asthma I enjoy curling and draughts, and scuba diving off the Aberdeen coast.

NOT KNOWING, SCREENING, AND OVERDIAGNOSIS

An essay on screening diagnostic processes and their effect on individuals, and implications for overdiagnosis. By Dr Owen P Dempsey MSc MRCGP

“(medical) man’s passion for ignorance dehumanises man in the name of a Cartesian humanism”

(Owen Dempsey 2015)

“In my view, this activity …….. reveals both a libidinal dynamism that has hitherto remained prob­lematic and an ontological structure of the human world that fits in with my reflections on paranoiac knowledge.”

(Jacques Lacan, talking about child development, in The Mirror Stage as Formative of the ‘I’ Function as Revealed in Psychoanalytic Experience, 1949, Ecrits p93)
This essay explores the effects of cut-offs (chosen for screening and preventive diagnostic tests, called ‘diachronic‘ tests here) on overdiagnosis. The need to do such tests is driven by a need for medical knowledge, they become an ideological tool perpetuating overdiagnosis, require a disavowal of ‘not knowing’ and objectify the individual transforming him or her into a subject-of-medicine.

It is acknowledged by those working within EBM and specifically in relation to diagnostic testing that language, the names given to the different aspects of testing and their properties is a substantial problem, but what is the problem exactly?

First of all a strange counter-intuitive but real example.

Following a discussion on the Evidence Based Medicine mail base JISC list, about the meaning and effects of sensitivity, specificity, prevalence and predictive values, Teresa came up with the following comment:

“”Oh dear! such a complicated topic. Going back to the RASTER study on MammaPrint, can you speak to the following clinician rationales and comment?

“I’m going to order a MammaPrint test for my patient, because if it shows Low Risk, we can be 97% sure my patient won’t develop metastasis and I can confidently recommend no chemotherapy.”

“I don’t think MammaPrint would be a good test for me to order for my patient, because even if she is likely to develop metastasis, the MammaPrint test would have a 30% chance of missing that and showing a false-negative Low Risk result instead—potentially misleading.”” (cite)

The MammaPrint test …… a way of determining the likelihood of developing metastases in the future.

My (brief) response was:

“The shift of the low-high risk cut off point to favour low risk is odd. It seems to favour (as in promote) specificity rather than sensitivity. This is odd because usually cut-offs have tended to promote medicalisation, as in most screening tests. But to decide on any particular cut off might be presupposing that there is a piece of knowledge, here called ‘risk’, that the test can fully characterise or obtain. Maybe it can’t. But maybe the testers don’t acknowledge that some things aren’t necessarily measurable and perhaps never will be. It would be interesting to know the confidence intervals for the findings of the study, it sounds as though chance may play a role.“

Interestingly, perhaps, there was no further response from the list, so far. (There has now .. 24/2/2015 and I will return to this)  But this has intrigued me and made me wonder if it had something to offer. What could I turn up if I attempted to ‘go to the root of things’?

Given a population with a significant (possibly) high prevalence of the target condition (in this case so called ‘high risk’ of metastases in the future), then, a high specificity at the expense of sensitivity can be misleading. Whereas, on the one hand specificity would protect the already low risk low prevalence population from false negatives, on the other hand, in the face of an important high prevalence diagnosis, (high risk of metastases here), then the low sensitivity will miss, in this example, 30% of those that might benefit from chemotherapy. This suggests that the cut off between low and high risk , should depend upon what is known of the prevalence of the risks, low and high, in the test population.

The more the prevalence of metastases, then the more sensitive the test should be, and the less specific, the rationale being that the more the prevalence of metastases then the more important it is not to miss them, simply because there are increasing numbers of them and the more forgivable it is to be less specific and to over diagnose those that would not benefit from chemotherapy as there are proportionately less of them. This is complicated. The example given suggests that the cut off inordinately favours specificity and I wonder how the authors justified their choice of cut off.

Of course for an individual the risk might be an unknown, if only because studies have not been done to measure risks of having or not having metastases without treatments, i.e. without a non-treatment arm. In such a case there can be no rationale for the cut off. In the example given it looks as if the population levels of risks have been estimated (but how accurately?) and a decision made for a cut off between low and high risk but the cut off has for some reason been inordinately skewed towards specificity. This could be because the tests cut offs were worked out on a low prevalence population but then inappropriately applied to a higher prevalence population. Does this sound possible?
I argue here that, amongst many difficulties, the root origin of the ongoing unstoppable epidemic of overdiagnosis is Modern Medicine’s desire to name that which it doesn’t understand, and to assume it can know that which it cannot know. Modern Medicine, for the ‘diachronic’ test, manipulates the cut off points for diagnostic tests to favour sensitivity, so that the borderline must always be assumed to be pathological. Note here however that paradoxically the cut-off for the MammaPrint test favoured specificity, which I cannot explain. It is used as the EBM cognoscenti would say as a ‘Rule Out’ test, fairly reliable at confirming you don’t have a condition, not so reliable if you do have the condition, best used for screening type tests where falsely ‘ruling in’ has serious consequences, that outweigh falsely ‘ruling out’. Here you might expect them to what to have a more sensitive ‘rule in’ type of cut off. Why would they do this? It had the effect of reassuring people they did not run a risk of metastases when they perhaps did, it would also reduce the number receiving prophylactic chemotherapy. However, putting this strangeness to one side for the moment I will persevere with screening diachronic testing.

Medical Technology is part of a diachronic process when it tries to predict the future, or the risk of future harm. It is diachronic because it is providing information that is applicable to a time period as opposed to synchronic, which applies to the state of the tissue today. This applies to most screening and preventive investigations, including private health care screening and cancer screening programmes. This is a huge profitable industry. It relies upon a sacred belief that tissues must reveal their futures up to the test, and more testing will provide more certainty. Medicine remains obsessed with the classification of tissue representations and now molecular appearances. The aporia of medicine is disavowed because they are the unanswerable questions posed by the borderline tissue of the breast biopsy: “What does this result mean for me, the individual in front of you?” Answer: “We cannot say, (because so much cancer is determined by random chance) which is why you must have the mastectomy, we cannot take the chance of not removing this indeterminable aporia.”

When a test is used to determine risk it functions to performatively name an individual and transforms him/her into a feminised subject-of-medicine with a dis-ease requiring treatment now or, if not, at least further investigation now or later. The test and tester and the tested have two issues to confront in general a) the dependence of the predictive value of the test on the sensitivity and prevalence of the condition and b) the dependence of the sensitivity of the test upon the choice of cut off between low risk (treatment should be avoided) and high risk (treatment can be recommended). The effect of the test upon treatment recommendations is critically dependent upon the choice of cut off. This choice, for conditions where the problem is diachronic, i.e. not synchronic with the timing of the test, has two further issues to resolve: a) the uncertainty of the level of population risk, b) the uncertainty of the individual risk even if the population risk is known, and c) the ability of the test to provide reliable information about the risk in question (e.g. of a person developing metastases in the future, or in a de novo screening situation (on a person with no previous symptomatology or signs of the disease in question) as in breast cancer screening. For many diachronic diagnostic situations there is no gold standard by which the test can be judged.

For example a screening test can lead to a biopsy reported as borderline: this might be called ‘indolent tumour’ appearances or DCIS (though both appear identical under the microscope). The pathologist may only be able say that this tissue has somewhere between a 1 in 4 and 1 in 20 chance of causing life threatening physical harm over the next 10 – 20 yrs, and it might be that the risk of coming to harm from other things is even greater, and that treatments themselves can cause harm (radiotherapy and heart/lung disease) , and there is lack of certainty about whether treatment actually reduces overall the death rate from all causes.

So even if the population level of risk is known, e.g. for 50 yr old women of a certain social class and nationality and with certain lifestyle risk factors there is no gold standard synchronic test that can be used to provide certain information about what will happen in the future. The best that can be done is to follow screened and unscreened populations over many years to see what is the excess level of diagnosis in the screened group above and beyond the number of deaths from the screened condition reduced in the screened group compared to the non screened group. This would represent over diagnosis. The problem with estimating sensitivity and specificity like this is that a) it does not reflect prevalence for other populations and does not reflect an individual’s unique potential for developing the target condition, b) the effect on treatment recommendations/decisions depends upon the cut off between low and high risk, which is in a circular fashion determined by a decision to make a recommendation for treatment even when the level of risk is highly uncertain and is even contested, and c) the screening test itself varies with time.

Another example might be the diagnostic criteria for the diagnosis of Munchausen Syndrome By Proxy (MSBP) also now known as Fabricated and Induced Illness (FII), these criteria were ‘described’ by Roy Meadow to characterise the mothers of women deemed to have deliberately murdered their babies. Several convictions partly based on Meadow’s ‘misleading’ evidence have been overturned, but many Family Court custody decision cannot be challenged because they are held in secret and the participants have to sign secrecy non-disclosure clauses. The diagnosis was in response to the problem of ill children without a diagnosis, and included the conundrum of cot death, or Sudden Infant Death Syndrome (SIDS). Many critics have claimed the ‘test’ for MSBP was over sensitive and not specific enough. It is possible its ‘cut off’ point was determined by an over zealous need to ‘know’ the cause of these children’s illnesses and deaths. Too many innocent families ended up being caught up in the process. I believe there are parallels with over zealous screening programmes in Modern Medicine today.

The contestations about the ‘right ‘cut-off for a diachronic test arise, I believe, when the test is incapable of providing reliable information about the future of a biological system. We know that so much of the future of biological systems is likely to be due to chance, literally due to random mutations as cells’ DNA replicates billions of times in the lifetime of one organism, (always remembering that such random mutations can also reverse harmful changes which is why some cancers may regress). The contestations are also influenced by three factors: a) the intrinsic level of variability confounding attempts to provide ‘scientific’ reliable information, and b) an intrinsic accultured scientific abhorrence of a vacuum of knowledge that demands that tissues yield up their futures to us now – the result of a scientific Cartesian enlightenment in the 17th Century when Man’s thought achieved a rational primacy underwritten by a faith in God’s benevolence, and c) a politically and economically motivated medical doctrine that places a primacy on preventing death over and above maximising quality of life today. b) above reflects man’s passion for ignorance, where here ignorance is the disavowal of simply ‘not-knowing’, the ignorance of our real ignorance. Modern Medicine in the West so far refuses to challenge the ideological strategies enforcing diachronic test cut offs that coerce individuals into harmful treatment programmes, and refuses to acknowledge that some (borderline) tissue appearances are uninterpretable, much like language is uninterpretable in the sense that we never can see inside to the meaning and intention of the speaker. The injunction “Be Normal!” of Modern Diachronic Medicine – objectifies the individual, and enforces a closure, gating of the universal within a normality-pathology opposition that cannot face up to the ontological difference of Heidegger, wherein the representation is different from the object by precisely the representation itself (see ref) . What the tissue gives up to the test, its sensed representation, is precisely what the tissue is not. Diachronic Modern Medicine dehumanises in the name of a Cartesian humanism that is deluded and grandiose.

The transparent sheet that separates us from our patients (and madness)

“Lets make it more than impersonal”

Who controls the content of the ideologically commanded medical consultation? Is it Public Health, The State, Business, or The Law? And what of the agenda and caritas? I’ve a feeling that it has  been getting harder and harder to discern much ‘caritas’ in consultations (those commanded by State Medicine under Capitalism) for the Heroin addict, or for the Patient-of-Screening.

Its hard to imagine anything much further removed from Freud’s consulting couch than the average GP consultation, with its eye contact, stethoscopes and prescription pads. If we, for the moment, take seriously the issue of the words we speak and what they mean, we can turn to Lacan’s mirror stage. We can all feel uncomfortable about the innuendoes, silences and mis-communications that pepper everyday ‘talk’ – but why should it be so hard to understand what the other person means? Why don’t they and their words seem to mean exactly what they say?

For Lacan, during the Oedipal phase, our ‘inauguration into linguistic consciousness’ (Judith Ehrer-Gerwich) is closely related to the trauma of an enforced realisation, in the mirror stage at about eighteen months old, of our superfluousness to our mother-figure, of no longer being the sole object of her desire. Language through words become the means of our demand for recognition, our quest for completeness. But these words we speak are constituted by a unsymbolisable trauma, our Real, a division that is what we are, divided within ourselves by a traumatic separation of our conscious language from our unconscious. Our unconscious is both ‘external’ to us and at the same time most ‘intimate’. Lacan’s describes this as ‘extimate’. The act of speaking itself is always re-dividing the speaker since the I that is spoken of can never be identical and simultaneous with the I that is speaking. I’ve laboured this point a bit, because its important, really interesting and hard to understand, let alone explain.

But why should this interest a medical doctor? And what of Freud’s couch? And how transparent is the sheet between doctor and patient – the wall of mi-recognition that is the truth of medicine?

If language is the ‘wall’ between analyst and analysand, the necessary mediation and mechanism of representation, and speech is both sensed and needs to be made sense of, then what use can the participants in a ‘conversation’ make of it.

Adam Philips, a psychotherapist and writer at a recent seminar, talking about some of his writings, including an essay: “Lets make it impersonal’, opened the debate by suggesting people at the seminar should feel free to a) be silent, c) to be incoherent and c) to free-associate. For, he suggested, it is sometimes the most incoherent free association that is the most striking. It felt like a luxury, possibly even therapeutic, to be invited to be freely incoherent. It is not often a medical doctor suggests the same to his client (always already the ‘patient’, the subject-of-medicine’, but not the ‘analysand’) in the medical consultation.

Through free association, the analyst’s role becomes ambiguous, a background role in a sense, there to prompt the analysand into a productive surprise at his own internal contradictions and e.g. slips of the tongue. There is a necessary distance, it is impersonal. It is argued, I think, that being too personal, communicating in such a way that gives the impression that can interpret, and that you known the hidden meaning of what the client is saying, would inhibit the client’s responses to his own unconscious, encourage the client to persevere with the script he is most comfortable with, his imaginary symbolic world (and avoiding his Real world), and may reinforce a tendency for the client to ‘look up to’ the analyst, or doctor, as the expert, with the ‘ medical gaze’ described by Foucault, he who knows the secret ‘things to be known’. Adam Philips argues, as well, that in the medical consultation, there are benefits in not being too personal, since maintaining a distance will allow the (now) ‘patient’ to bring forth their own script unencumbered by the doctors probable mis-recognitions and misleading stray alleyways. Keep a distance and let the patient tell their own story, start the consultation by keeping your (the doctor’s) mouth shut and the ‘patient’ will reveal all.

However, and here is the turning point in this short essay, at last. I believe there are consultations that are set up as ideologically commanded events, the ideology being Modern Medicine under Capitalism with its injunction: “Be Normal” under which the commanded events are those that are initiated by the State and other Capitalist Corporations. The ideology is hegemonic, it promises that which it presupposes we already desire, whether it is death avoidance, a marque of first class ‘ill health’, or some other ‘consumable’.

So, to be clear, here I am not referring to the consultation where the client decides to go to the doctor because they have a problem. Here, instead I am referring to consultations where the individual has been invited to attend, or has to attend to continue medication. Transformed into a patient by diagnostic ‘naming’ processes in which so called risk factors have been transformed into dis-ease, or where so called normality is forbidden, wherein normality is itself a risk factor as in attempts to ‘catch it early’ in cancer screening programmes. I am also talking about, for example, the consultations in addiction services where addicts tend to be prescribed their oral substitution treatment (OSTs, Methadone or Buprenorphine), and where they sometimes engage in psycho-social-interventions and motivational interviewing.

In my experience the consultations can be dominated by a script that seems to have been learnt by the client, and a script encouraged by the clinic. A script that is centred on some jargon like ‘recovery’ or ‘low threshold prescribing’, etc; dominated by the visible-safety of prescribing, the number of days of the week the client must be physically observed taking their OST, and/or the number of days of the week the client has to collect their prescription from the pharmacy. Decisions on these points are in the gift of the prescriber, and depends upon a professionally normalised, guideline and policy regulated, perception of the client’s (and others) risks of coming to harm through overdose, which in part depends upon their drug taking history and the evidence from urine testing. This is a highly regulatory environment, within which it is difficult to create space for other non-regulatory scripts.

I do wonder how often the addiction consultation remains within an impersonal, regulatory framework, dominated by risk management. How often the client embarks upon a speech intended to reassure the doctor about risk to obtain relaxed prescribing measures. Or how often a wall of silence pervades the air as the client knows to try again is pointless as he has tried and failed so often before. Or how often the doctor dominates with questions about risk.

Whilst it is essential to manage carefully the risks of prescribing highly dangerous medications, medications that have been directly implicated in deaths through overdose, is it possible to be more than this impersonal? Is it possible to stand away from regulation and safety, not to become more personal but to become more than just impersonally interrogative? To encourage some free association and incoherency, to observe for contradictions and ‘slips of the tongue’ – to provoke ambiguously, to suggest the client tries a spell on the couch?

Whilst impersonal communication styles can be informative, in the same way that a YES/NO answer questionnaire can be informative; and whilst that can even provide space for a ‘patient’ (with a problem) to perform the script they had planned all along, if, on the other hand the script is authored primarily by the State or corporate industry, as in much preventive public health medicine and addiction clinics, then the doctor/analyst has a role to subvert the script to provide space for the client, to provide opportunity for the client to challenge the script and themselves, if they wish. Is it worth breaking down the regulatory iron wall of communication and replace it with Freud and Lacan’s leaky wall designed to allow the analysand to speak with him/herself, to explore his relationship with his desire, that nature of the object of his/her desire, and to become the analyst.

What does the client say about his/her relationship with the drugs? What do they say about why they keep coming to the clinic?

Medical Fascism, Screening and Overdiagnosis – Modern Medicine is in Denial.

“In its pure form, fascism is the sum total of all irrational reactions of the average human character.”

(Mass Psychology of Fascism 1993 Wilhelm Reich)

Fascism is a hugely emotive term for good but also terrible reasons, but is it an appropriate term for aspects of Modern Medicine? Is there anything fascist about the practice of Modern Medicine? Does humanity have anything to fear from Modern Medicine? Might there be a good reason for using the term? Might using the term alert us to the nature of the powers of Modern Medicine, its objectives, strategies and mechanisms, and provide a rationale for resisting them.

Foucault said there was a crisis of anti-medicine, and that resistance is in a sense futile:

http://www.michel-foucault.com/ecrits/foucault1.pdf.

“On the other hand what appears to me to be much more interesting and which poses the real problem is what one might call positive iatrogenicity, rather than iatrogenicity: the harmful effects of medication due not to errors of diagnosis or the accidental ingestion of those substances, but to the action of medical practice itself, in so far as it has a rational basis. At present, the instruments that doctors and medicine in general have at their disposal cause certain effects, precisely because of their efficacy. Some of these effects are purely harmful and others are unable to be controlled, which leads the human species into a perilous area of history, into a field of probabilities and risks, the magnitude of which cannot be precisely measured.”

Let us  imagine, for the moment; that the current Evidence Based Medicine strategies of combating overdiagnosis are failing, that no matter how transparent information is, no matter how much regulation there is, no matter how much the patient’s values are incorporated into decision making, that nonetheless over diagnosis and medicalisation will continue to grow.

Whose fault is it anyway? If a discursive formation, like for example the practice of Medicine as a social apparatus with all of its legal, political, economic and human/‘ethical’ inputs, interacting, sometimes mutually supportive sometimes mutually contradictory, if this formation has a strategy evident through the reality and concrete effectiveness of its practices, and these practices seem to be causing more harm than good, then whose fault is this? Does it become difficult to critique the formation because individuals who ‘believe’ in the ethical integrity of the ‘practice’ take it personally? This is probably so. But supposing it isn’t anybody’s fault? Supposing the strategies, objectives and mechanisms were outside of personal control, suppose the discursive formation has a life of its own , then what? Its not as if we can point to any one individual promising redemption, leading the way, no extreme political medical leaders mesmerising us all.

Do we need to take Medicine’s inherent contradictions more seriously. Although efforts to regulate the drug industry are important and may reduce the rate of growth of medical harm are they just a  smokescreen for the underlying real problem? Let me just cite one apparently imponderable conundrum, a very important and vivid example. There are sharply polarised, indeed mutually contradictory and incompatible,  views about the a) relative size benefits and harms of the UK breast cancer screening programme and b) whether it should continue in its present format if at all. The views are of people of great official esteem, Dames, Professors, all lined up against each other. Note, these views are just of shades of difference, they are mutually contradictory, they cannot both be right. Some countries are calling a halt to their breast cancer screening programmes, some like the UK are extending their programme to a wider age range. I don’t believe for one minute that the pro screeners are just in it because of vested interests, either in terms of reputation, power, recognition, status or money – those these can motivate any of us. It is highly likely that the opposing camps are both made up of sincere caring folk who believe what they are doing is in the best interests of the public at large. So how come the polarisation? And notice this is a polarisation that is scientifically based, people disagree about levels and natures of harm as well as possible benefits.

Baum (a now retired, well informed and highly esteemed professor of breast surgery and long time critic of universal breast screening, puzzled by the conflict) asked if something ‘ideological’ is going on?? I say: “Yes indeed it is!” , but,  I suspect,  not in the sense that he meant it. Using ideas based on Althusser and other French theorists of the 1960s and onwards, to be ideological is to be transformed as an individual into a subject of the ideology, into someone who believes fervently in what the ideology seems to promise, in one camp the ideology of ‘catch it early must be good’, in the other camp ‘first do do no harm’. This is uncomfortable reading because it does imply we have limited if any control over our beliefs. It is essentially quite anti-humanist and pessimistic.  It may be ‘a process without  subject’, but then again, after all,  the human species is frightening.

Breast cancer screening is such a good example because of the visibility of its contradictions and non-senses. It is a good example of Modern Medicine’s huge struggle over the nature of technological representations of tissues that are on the borderline of normality (mammogram pictures, PET scans, biopsy samples under the microscope), a struggle that presupposes that there must always be a discernible normality-pathology distinction. But what is the power of this presupposition?  If fascism is the use of power to persuade people to behave in ways that are not in their best long term interests and moreover to behave in ways that cause net harm to individuals – to be coerced into feeling willing to be harmfully treated then the pro-screening camps of Modern Medicine have some features of fascism. This is more coercion than nudge.  The strong language is needed because it needs resisting, effectively.

Because EBM is stuck within the normality-pathology opposition and as a discursive formation believes that it is possibly to know the meaning of the borderline tissue representations brought forth by technology, then EBM, as it stands, is poorly placed to resist overdiagnosis. Its own internal hierarchies of evidence tend to be based on the apparently quantitatively measurable and therefore more valid, even the Qualitative methods make assumptions about the way people’s enunciations and actions should be interpreted. My argument is not with these internal hierarchies, for me all of the Science within EBM makes the same mistake which is that of assuming that all things can be known if we throw enough technology or interviews at it.

Both of the camps: pro and anti breast cancer screening, make the same mistake of assuming that scientific research will provide answers in a way that is independent of the ideology of the dominant Medical Formations (with their contradictory political economic and ethical inputs). Today the dominant ideology is ‘Catch it Early’ : The TV adverts say: “Have a health check, its easy and only takes a few minutes”. The anti-camp thinks the answer lies in a more objective appraisal of the evidence, the numbers.

Lacan’s seminar Science and Truth critiques the relation between Science and what he calls the post Descartes Subject-of-Medcine.  Mis-recognition is the Truth of Medicine, it is the Truth that should provoke a crisis for Evidence Based Medicine.  If there is truth here it is to acknowledge that for screening, the tests provide meaningless information much of the time, borderline changes are an unknown, they do not have any future that we can predict. Even, for the positivists, the most normal tissue in the world is constantly randomly mutating, cancers come and cancers regress. I’m not at all sure it is possible to resist the efforts of those determined to look harder and harder, more deeply into the molecular structures of our tissues, I don’t think it is. But I have very little faith in a model of Medicine that tackles the problem of overdiagnosis with the techniques and presuppositions that cause overdiagnosis in the first place. I think that the preventitive aspects of Modern Medicine, such as screening,  have fascist qualities, I also think, following Reich and indeed Freud, that  we all individually have fascist tendencies and this is part of our humans nature, our aggression, our insecurities. This explains why we are all susceptible to ideological manipulations by ideologies out of human control, this is why good people do dangerous things. I would say though let us continue to worry away at the aporia posed by the borderline, the lack of a gold standard as a foundation for test interpretation, the non-sense of ROC (test receiver operating characteristics) curves in these situations, even the normality-pathology opposition, and lets not be in denial about what we simply do not know.

The clinamen of Lucretius where “Error is the Mark of Life”

“Life is structured like a language and disease is a misunderstanding” (Georges Canguilhem)

Cancer and ‘Chance’ – where Error is the Mark of Life, without which evolution would not have been possible. Lucretius invoked the swerve of chance, the ‘clinamen’,  to explain how atoms first collided so that anything ‘at all’ could happen. Cancer mutations seem to be a chance random event, mostly.

You might think that if it was known that cancer is mostly due to chance and not to environmental factors that this would be a good and reassuring thing to know.  After all, we would no longer have to worry so much about the possible harmful effects of lifestyle, diets etc. and could be more carefree.

A study (see REF below) has just asserted that because the rates of cancer are directly proportional to their stem cell division rates, that two thirds (21) of the cancers examined are due to chance mutations and not environmental factors, and that one third of the cancers (9) had rates that were in excess of that expected from the stem cell division rate, and therefore have an environmental influence.  Notably though breast cancer and prostate cancer were not examined because reliable stem cell division rates are not available, or so the authors claim.

However, even if breast cancer is mostly due to chance; and even if at the same time cancer becomes a ‘better’ way to die (see Richard Smith’s blog in the BMJ) than other ways (time to say goodbye, put affairs in order, achieve some ambitions); ‘eradication’ of cancer is cited still cited by the authors (and notably juxtaposed here as what the Subject-of-EBM should next think) as requiring early diagnosis.  Early diagnosis and better treatments rather than cure is receiving an extra bright spotlight. If cancer is to be (officially) less feared, this does not address the decisions to be made about borderline tissue representations from screening investigations, it also emphasises that a negative screening test is no longer reassuring since once the result is known, the ‘chance’ mutation could occur in the very next second; this sets up a paranoid repetition compulsion, this could have two opposing effects:

“Cancer is not only an OK diagnosis, ‘Phew I can say good bye’ and as Bunuel says I will know who closes my eyes…it is also (perversely) desirable because it means it might have been discovered early enough, that is just after the ‘chance’  mutation’  has occurred, in time to be ‘cured’.”

A negative result leaves a persistent (fear of the) fear of cancer; and a compulsion to re-screen yourself as soon as possible: constant anxiety and constantly repeated screening is the result.  It can be seen that the ‘chance’ factor adds an important element of time-pressure. A logic of time now has interpellated the subject as always already in the position of requiring urgent screening a moment ago. I do wonder whether there may be additional factors explaining the exclusion of breast and prostate cancers from the study on ‘chance’. Is there some reason why it would be unacceptable to say breast cancer is due to chance?  There is a vociferous element advertising preventable causes of breast cancer but I don’t know how powerful they are. It may be that the division rates for breast and prostate cancer are difficult to estimate for technical reasons I am unaware of.

An  unpredictable ‘chance’ cancer is Freud’s death drive (instinct) at work, it results in an emotional discharge and libidinous drive, the life instinct, to oppose it. The less predictable the harder it is to oppose, and the more sado-masochistic energies are expended paranoically in detecting the moment of mutation so that it can be neutralised. The screening frenzy that is ensuing is a self fulfilling prophecy since borderline diagnoses (or ana-gnoses, **qv) are compelled to appear and to be diagnosed as ‘precancerous requiring treatment’ by ever-deeper penetrations into the tissues/molecules by technologies revealing ever more mysterious representations that must be explained.  The cunning secret of the Order of EBM is that its ana-gnostic representations do not have a discernible meaning – they make non-sense, and it is this that must be disavowed.  If the subject suffers a crisis of investiture (after Santner, and his analysis of Schreber’s memoirs of his illness in ‘My Own Private Germany’), then transgressive behaviours may result.

REF [Variation in cancer risk among tissues can be explained by the number of stem cell divisions: Science 2 January 2015: Vol. 347 no. 6217 pp. 78-81 Tomassetti, Vogelstein.]

The ‘Abstinence’ rhetoric and the Pathological Heroin-Thieves

I argue here that Addiction Services that are abstinence focussed inhibit therapeutic change.

A broader perspective needs to take into account the client’s relationship with the culture of addiction as one possibility for what is an essential socialisation, but a possibility open to alternatives and change. In other words if the client does move away from the culture of addiction, how can it be replaced by an alternative and does this require some fundamental changes in the client’s sense of their place within the new culture or symbolic network., i.e. a change in subjectivity or neo-subjectivity.

The ‘addict’ can present as an ‘underground hero’, with a degree of ambivalence and ambiguity, with The Prohibition creating jouissance, a sense of hard to symbolise pleasure/excitement derived even from pain, from the act of doing something prohibited, officially illegal. This creates various not exclusive possibilities: the ‘need’ to use to prevent withdrawal symptoms and the nature of the possible symbolic relationship(s) that the addict has with the drug itself,

This sets up two extremes neither ever wholly and solely true but both always materially effective, namely two gendered possibilities. The psychoanalyst Lacan describes the individuals power relation to an ideology as a gendered ‘sexuation’ that is not bound to a biological sex. The masculine is wholly enflamed by the symbolic structures but feels powerless and strives to have power by feminising the ‘Other’. The feminine is not wholly enflamed by the symbolic and is ‘not-all’ an object of mystery for the masculine, and who feels a desire to be of service to the masculine. The gendered relationships her firstly, is with the drug as an object of value for the addict, “I enjoy it….” or secondly, the addict as an object of value for and working for the drug: “it’s holding me back…”. The relationship with the substance misuse service is judicially determined by the abstinence rhetoric and feminises the client as external to (or at least not fully captured by) the symbolic network and pathologised judicially as an ‘addict – criminal or patient’. Alternatively the client can be given gendered options by the service, (which is a Lacanian psychoanalytic approach) to examine the nature of the relationship with the drug and the service. The relationship with the addiction is one with a socialised intersubjective culture, and also one with its own phantasmic structure and relationship with an Other, a Look (Sartre), as part of a scene as if observed. The behaviour may be perceived as pleasing for the Other accruing admiring praise, or it could be perceived as creating pain anxiety or anguish for the Other. The behaviour is part of a human drive emerging from the constitution of subjectivity as it emerges through language as either a masculine complete submission to the symbolic resulting in a powerlessness, but ‘with its escape clause’, a fantasy that there is an Other, the primal father who does have all the power; or a feminine emergence from the oedipal process as not completely contained within the symbolic,  a part has escaped, so that she does not fully exist within the symbolic and is structured against the masculine for whom (?stereotypically) she may desire to be an object of value.

Clinically an early key issue is the nature of the client’s relationship with the addiction, what is addiction? are they ‘addicted’?, is the drug of value to them? e.g. do they control the drug (and why?), or, are they of value to the drug, does it control them? An issue is whether losing the addiction will lead to its replacement with a different object of ‘addiction’. Is the relationship hystericised (feminine, repressed and disavowed, which is common) or is it perverted, the role played of the ‘underground hero’, the masculine role of the Father of Enjoyment who knows the things to be known but who may also paradoxically be acting out rage against his or own femininity, by feminising others. Is the aim of analysis to disrupt or to stabilise the client within the symbolic network or culture of addiction.

The ethos of the service may demonise the addict as the Heroin-Thief, who has metaphorically stolen our enjoyment, stolen our Heroin, who must pay us back, by providing us with their alway assumed to be heroin infused urine, so that, in the process we feel a libidinal gratification.

The current funding indicators and official policy promote abstinence, investing the service with a gendered masculine role in relation to the clients, this will either reinforce the hysteric, or set up conflict with the pervert; in either case it forecloses possibilities for change. This abstinence culture creates several roles for the clinician:  a role that is seen by some clients as a supportive ‘dealer’ providing something for nothing, or as an insurance salesman providing something for nothing, and/or as a policemen simply interfering with the addicts smooth symbolic functioning. None of these roles permits effective exploration of possibilities for changes in the client’s relationship with the addiction culture/society. Effective work with clients, at least work capable of promoting change if it is desired by the client should therefore avoid an abstinence driven culture, and focus more on exploring the client’s signification in relation to his addiction culture.

Lacan’s Logic Of Perversion and the Medical Fantasy

 

It is something called ‘jouissance’ that the Perverted psychical structure encounters – the sense of not being desired for your own sake but of being a chattel to be used for somebody’s pleasure, as an object. Unable to be desired must be traumatic, and must lead to an intense need, but a need based on a cruel objectification of the other, and a need to seek out a suitable victim for the pervert’s non-desiring but needy pleasure.

The jouissance of medicalisation has: 1) a political/cultural disenfranchised ‘excluded’ subject to be enjoyed, 2) a Medical Target within that disenfranchised population and 3) an ‘example’ of the structure of perversion that reveals the horror of the Medical Fantasy.

The cultural extension in the West under capitalism, called an ideology by some, comprises the special sub groups within the target population, and may include: the disenfranchised unemployed (already guilty of general fecklessness and incompetence, child abuse, domestic violence, crime, addiction, etc), perhaps religious ‘minorities’ (e.g.Muslim and Jews), women, and in particular, mothers. The target population for Medicine is universal, and is the ‘to be excluded feminine or feminised subject’, and is universal, i.e. all subjects. The examples that reveal the horror and fear of the JOUISSANCE occur when agents of the Medical Order go too far and act out the fantasy of The Establishment.

The perverse agent might, like Meadow and Southall (the ‘star’ expert paediatricians who falsely accused many mothers, in the late 1990s earl 2000s, of murdering their babies using a bloated diagnostic category they helped create: Munchausen Syndrome By Proxy) ,  do this because of a crisis in their own investiture(s) (perhaps as children ‘maternal’ or “oedipal’ and then later in life cultural or social) resulting in a libidinal structure of perversion (in a Lacanian sense) with their symbolic network, they act on the fantasy (of The Other in this case Medicine) and enable it to irrupt as The Real into the Symbolic. Their acts betray the fantasy of The Medical Order which is to medicalise all, to impose The Law as the injunction: “Be Normal!” upon all.

It is however difficult to ‘know’ the cause of a perverted psychical structure  – maybe it can’t be known. It may be the crisis is within the dominant Modern Medicine ideology, its disavowal of ‘not-knowing’ resulting in a constant misrecognition of e.g. test results, tissue representations (e.g. mammograms).

Particular perverse agents focus on particular ‘medical crimes’: the ‘murdering mother’, the ‘cancer-thief’ (who is guilty of having stolen the ‘enjoyment-JOUISSANCE’ of the possession of the cancerous body part that rightfully IS TO BE ENJOYED BY (hence the jouissance) the Primal Father The Medical Pervert e.g Halstead in the 1920s, or today, perhaps, Mr Paterson, and indeed the Logic of National Cancer Screening Programmes, with their emphasis on ‘early diagnosis’ first introduced, tellingly I think, by The Nazis in the 1930s.

See Judith Feher-Gurewich in Cambridge Companion to Lacan page 194:

Jouissance drives the pervert on. Not to own but to have the right to ‘enjoy’ provides the libidinal gratification provided by the process of seeking out the object, the target, the thief, as in an inquisition.  If jouissance does not employ ownership does this disrupt the Marxist analogy/exension of debt peonage already described (the notion that the system ensures debt can never be paid off but grows at the same rate as repayments are made)? if the ‘right’ is to enjoy something how is this different from owning it: you are no longer the object of desire as such, the punter does not desire The Woman, or even to own her, marry her etc, but just to enjoy her, to reify her, dehumanise her. When the subject sacrifices the Body Part, The Body Part is then ‘owned’ by The Medical Other and State, but the woman has been ‘enjoyed’ – has encountered the JOUISSANCE of The Medical Other.

Fodder for Medical Perverts – Zizekian?

My latest work is exploring a Lacanian approach to the discourse analysis of Evidence Based Medicine. It is looking at a discourse of (and the site of struggle around) what was called Munchausen Syndrome By Proxy (or FII now, Fabricated Induced Illness) where mothers (usually) allegedly cause symptoms in their children to ‘attract’ medical attention for themselves, so it is said anyway.

The basic idea here is that we can use psychoanalysis to explore notions of Prohibition, Truth and Enjoyment as a tool to tackle ideology (after Parker, I, after Slavoj Zizek).

The analysis focuses on the activities of ‘superstar’ expert Paediatricians Roy Meadow and David Southall. They accused many mothers, in the late 1990s, early 2000s, of harming and even murdering their babies, and provided ‘evidence’ for courts, but several cases have now been overturned (Clark, Patel, Cannings, and others) and both Doctors have fallen from grace, discredited (though with some champions still) , and were struck off the medical register at different times for giving e.g. extreme prejudicial stereotyping, ‘simply wrong’ information, ‘grossly misleading evidence’ and showing’ ‘deep seated attitudinal problems’..

An account I am creating suggests these individuals, (frozen psychically as objects of jouissance for The Other, and horrified by the (m)Other’s lack of The Phallus) demonstrate the acting out of the clinical psychoanalytic structure of ‘perversion’ (using Lacan’s particular use of the term) , and that their extreme grandiose lawlessness as ‘Primal Fathers’ exposes the anxiety and auto-erotic drives of Medicine (its ‘obscene superego underbelly’) itself functioning as a ‘stable’ discursive formation which, (as a gendered masculine agent), demands subjects to “Be Normal!”, and which disavows ‘not-knowing’ (e.g the cause of ‘cot deaths’), so that Medicine, through discourses, situates subjects (gendered feminised agents) as that which must be known (possessed or enjoyed), firstly: reified objects (patients) and secondly: as possessing objects of desire they must hand over: such as the ‘murdering mother’s baby’, ‘the intoxicated addict’s heroin’, ‘the cancer-thief’s cancerous tissue’, ‘the dis-eased patient’s pathology’ etc.

I argue that this process (Evidence Based Medicine under Capitalism) is ‘Feeding The Beast’: our infinite capacity for medicalisation (or overdiagnosis). The transgressive, unstable, uncertain-gendered, and perverted rogue doctors make the exploitation (The Real) in this process visible to all.

Are the ‘medical perverts’ a necessary production of the antagonisms of the ideology that is Modern Medicine under Capitalism? If they are where are they today?

Misrecognition is Medicine’s Truth

The apogee of Modern Medicine is the universality of Dis-Ease. Achieved by the injunction: “Be Normal!”. Which paradoxically forbids normality; and is the injunction of a masculine phallocentric Medical Establishment.

If for now we Agee that Medical Perverts exist – who have a psychical structure of ‘perversion’ with the object of their medical practice. Which is to say those who are driven to constantly re-break and re-make their own Great Law, behave as Obscene Fathers, as the Primal phantasmatic Father come to life. Those such as paediatricians Meadow and Southall responsible for the wrongful surveillance of and imprisonment of mothers accusing them wrongly of murdering their babies. Creating a dis-ease to fulfil their libidinal needs, where no dis-ease exists : Munchausen Syndrome By Proxy. If we agree these Perverted Psyches function we can ask: why do they?

Are they the inevitable result of the present antagonisms within the neurotic (majority) structure of the dominant ideology (which it is the role of the critical intellectual to keep open) and which is the aporia of the zero point between meaning and non meaning, arising within Medicine within a framework enclosed by the normality-pathology opposition. This is like the Subject-Object opposition – the result of diagnostic processes being applied to the healthy asymptomatic individual – a process otherwise known as screening; the apparently harmless innocent (and profitable for some) ‘health check’. A process which abhors the vacuum of knowledge which is not-knowing: why do cot deaths occur? Why do cancers occur? Why do people become Crack, Heroin or Alcohol addicts? Why do people become depressed? These questions all become sites of struggle and the sites of creation of diseases, overdiagnosis, medicalisation, the manufacture of the de novo patient and medical hegemony.

The process of diagnosis for the asymptomatic individual does two things, firstly it confronts Medicine with the uninterpretable tissue representation of an ‘unknown’ anticipated future and secondly and conversely it a performs a misrecognition as it names the tissue to provide an assertion of ‘known’ anticipated certainty that transforms the individual into a now reified patient. The misrecognition in diagnosis reveals the structurally unavailable Truth – the encounter with the zero point of just ‘not knowing’ results in the misrecognition. It is possible, since the representation can never be adequate to the thing in itself, that this produces a libidinally charged remainder, an ineffable left over sufficient to excite further creation – the creation of the horror of the phantasmagorical apparition that is the Medical Pervert, the Obscene Father, a phantasm become real. Only visible because of the materially concrete actions and transgressive behaviours that break The Law (of the Medical Establishment resulting in a public defrocking by the GMC), whilst exposing precisely that which has secretly been sustaining that same Law all along. The Medical Pervert for example publicly stereotypes the always already guilty murdering-mother, and creates a new syndrome to match the MSBP; a bit like saying serial murderers all suffer from a medical syndrome, a fatal assault by proxy syndrome.

Across Medical practice the population at large is named as universally dis-ease ridden, this is the apogee of Modern Medicine.

Q. Is the pervert constantly looking himself in the eye and seeing Evil, with a gaze that directed outwards seeks out and names Evil In an excluded other, such as the murdering-mother?
Or do we all have a tendency to do this, part of our cultural prejudiced heritage?

The Sublime Object of Medicine

In the latest addition of the BMJ Margaret McCartney (BMJ 2015;350:h439) asks if : “All knowledge is Power”, and she critiques the diagnostic uses of genomic industries such as ’23andme’.  I think the converse is true and reveals a truth behind medicalisation.

“All Power is through the illusion of knowledge”

Medicalisation and the abuse of ‘diagnosis’ (using healthy people to create disease products for a capitalised Modern Medicine) is ensured by Medicine’s insistence upon ‘knowledge’ (and a consequent disavowal of ever not-knowing). This requires a ‘blindness’ to ‘not-knowing’ e.g. the inability to not-know or a blindness to the forbidden acknowledgement that the doctor simply does not know what a given test result means (the classic example is the borderline tissue representations in breast biopsy samples) – or even that a particular test might produce an uninterpretable tissue representation.

The ‘blindness’ to not knowing is the result of the way Power operates through the discourses through which individuals and the various Establishments (including Modern Medicine) communicate. To be a Medical Bureaucrat, a Doctor, Nurse, or Patient is to be a Subject-of-Medical-Science, living in a kind of dream world where to be Healthy is paradoxically forbidden. The Power operates because of our constant individual desire to a) find ‘love’ (to find the ultimate solution to the void within each of us) and b) in a magical way, have faith in a Big Other, who we imagine, guarantees that love. A faith that guarantees material behaviours that ensures our contribution to the continuation of the illusion and our blindness. How else can we explain why good people do such dangerous things?

How else can we explain what is likely to be a continued exponential growth in levels of medicalisation and the abuse of the diagnostic process on the healthy. What we can be sure of is that the continued appeal to rationality, transparency and science, eg more shared decision making and use of things like Subjective Expected Utility Analysis etc, will only perpetuate the particular problem of the medicalisation of the healthy, precisely because it perpetuates the illusory blindness to not knowing. If a test is likely to throw up an uninterpretable result and provoke a coerced medicalisation involving harms for sure and no known benefits, then why do it? The classic slogan that appeals to our libidinal desires is “Catch it Early” – its Power is in its Promise of All Knowledge. Medicine is making objects of the individual and treats the individual as if they are a thief, someone who has stolen Medicine’s enjoyment,stolen Medicine’s Sublime Object, an object that is always a mystery but manifests itself in the tissue representations brought forth by ever more deeply penetrating technologies.