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.

The medical test, dia-gnosis, personalised theranostics, capitalism and ‘process ontology’ – Marx was right

“Biological normality is an unenframeable and enframing social construct and a discursive practice that by being both mandatory and impossible engenders a crisis for the subject and categories of pathological tissue or madness or amorality that can be infinitely expanded and, as ‘flesh’, incessantly sacrificed and consumed as the hyper-precarious in debt ‘patient’ and ‘medical expert’ enjoy a consummation in the perverse sado-masochist torture chamber of unfettered capitalism.”

Owen Dempsey 2015

Just as geneticists no longer think of a gene as a ‘thing’ that determines traits but regards genomics as a much more complex process, in a similar way I think we should think of diagnosis not as an end in itself but as a process.  This is a ‘process ontology’, (of the kind explored by continental philosphers such as  Heidegger, Deleuze and Badiou), such that the process itself leads to new ways of Being. For geneticists epigenesis refers to the way the environment, including environmental changes due to behaviours, can intertact with the genome to influence our natures. For example studies suggest that smoking in adolescence may lead to an increased likelihood of obesity in the adolescent’s grandchildren. So too for diagnosis the process of diagnosis results in a new way of Being. In a way Marx’s historical materialism which suggests human abstractions and thought change over time in response to changes in social and economic environments is also a form of process ontology.

This is a challenge to the traditional notion of a diagnostic test, as exemplified by the Oxford Handbook of Clinical Diagnosis, which portrays a diagnosis as something you may have or are unlikely to have, something a ‘diagnostic test’ determines. This traditional notion  sees the result of a screening test as ‘more of a presenting complaint’.  This is harmful because it prevents us seeing the screening test as part of a very important diagnostic process.  I think it is better to characterise all medical investigations as part of a diagnostic process and this includes elements of history taking and examination and even therapies.

What they all have in common is a differentiation of the subject between two or more different potentialities, “you probably will get ill, you probably won’t”, “you probably did have cystitis or you probably didn’t”, “you probably are anaemic or you probably aren’t” , “you probably should have a biopsy or you probably shouldn’t” – hence the name: dia-gnosis = ‘to know between’.  It is of course possible to conceptualise, develop and use tests to achieve particular diagnostic functions, to achieve more or less certainty about the presence or absence of a present or future pathology or benefit or harms from further diagnosing.

The screeningtest performed by default, invitation or request for a ‘condition’ in an individual who does not have symptoms of that condition is also a medical test, and therefore part of a diagnostic process. It determines a difference between tissue or organism potentials. The screening medical test is of particular interest because it operates at the borderline, and exploring this borderline reveals some of the dynamics influencing the process ontology of overdiagnosis.  (Where overdiagnosis is the result of medical testing that reveals a positive pathological potential that is exaggerated, wrong, false, and  misleading and leads to further diagnostic processes of one sort or another.)

We ‘think’ the borderline representations of tissues or tissue biometrics from screening tests of diagnosis as the abstract ‘form’ of thought that is ‘pathology’ or the way we think about and value and imagine ‘pathology’ – an abstraction that by the nature of this abstract ‘form’ necessitates something that is ‘not-pathology’ and this is the impossible fantasy of a risk-free subject, also referred to as the ‘normal’.  It is this borderline between an abstraction pathology and its imaginary demanded and impossible opposition ‘normal’ that is dynamic and shifts in response to advances in technology, always at the limit, posing unanswerable questions that demand to be answered.

As technology advances and new tissue representations and biometrics are produced such as genetic fingerprinting to predict cancer risk, so the nature of our subjectivity changes, as we are made more biologically insecure by being ‘securitized’ by diagnosis.  This is a process ontology, an anthropological mutation that is creating a new way of Being for humans. The process is compounded and accelerated  by three aspects of another process:  neoliberalism in times of ‘austerity’, which: a) marketizes diagnostic processes for profit b) demands individual self-surveillance creating more biological insecurity and a subject-of-precarity and c) uses the rhetoric of austerity, debt and benefits to threaten and bribe to exclude marginal groups and enforce compliance with state or market diagnostic processes.

As well as market and bio-political processes to enforce secure citizenship, entitlement to benefits and temporary hoped for reassurance, diagnostic processes (such as the MammaPrint genetic fingerprinting test to estimate risk of recurrence after treatment for early breast cancer) involve a trade off between those that shall be spared unnecessary further diagnostic processes (eg not receiving chemotherapy after breast cancerbecause it won’t help) ) and those that may be excluded from receiving beneficial diagnostic processes (ie not receving chemotherapy after breast cancer when it would help).  At a population level some are spared at the expense of the  neglect of others. This requires a valuation of a cut-off point that is influenced by opposing pressures such as the need to penetrate the market by demonstrating cost savings, or to appeal to manufacturers of chemotherapy by maximising treatment levels , or to reassure doctors/patients averse to over treatments, or to reassure doctors/patients averse to undertreatments. These influences can account for the way diagnostic processes are researched and reported. The health insurers monitor claims for molecular diagnostics because of ‘indication creep’:the increasing use of tests outside of approved guidleine criteria suggesting that healthcare costs will increase even if a test is marketed in terms of reducing costs.

On a pessimistic note, surprise surprise, with the a) Transatlantic Trade and Investment Partnership (TTIP), b) the dismantling of the UK NHS under an ever more neoliberal state institution, and c) the hunger for the markets to form partnerships between medical managers of doctors, medical intelligence suppliers, therapy and diagnostic distributors, health insurance provison and coverage criteria, and medical diagnostic and therapy manufacturers (also known as theranostics and personalised  medicine)  – we are seeing, in the UK at least and probably globally,  the tail of unfettered capitalism wagging the tail of the overdiagnosis doggie.

The uncanny creature-subject of healthcare in the ultra-neoliberal 21st centrury: Fiddling whilst watching Rome burn

Three separately voiced Neoliberal mottos heard in the past 24 hrs after the Tories win a majority in the UK:
 “I’m passionate about free enterprise …..”
“I believe in gving people the freedom to make their own decisions…”
“centralised government is ‘broken’ so we’re devolving more powers to the localities…..”

And in the news two days ago:

In an unprecedented intervention, the medics – who represent all 21 medical royal colleges in the UK – said too many patients were being forced to endure tests and treatments which could do more harm than good.

They said the payments system in the NHS, which means hospitals are paid according to the number of procedures they perform, and GP pay linked to diagnosis and treatment, could act against patients’ interests.

The senior doctors said it was time to “wind back the harms of too much medicine” and replace a culture of “more is better” with balanced decision making.

If you look at these two sets of quotes together you are looking at two opposing and mutually different social pressures on healthcare. Its not immediately obvious though.
What a waste of time – the Medical Colleges call for less unnecessary healthcare whilst standing by and watching the dismantling of the NHS, the relinquishing of state responsibility for health security, and the unrestrained exponential marketisation if healthcare.
The recent Tory victory in the UK elections and the ongoing privatisation of the NHS in which the state has relinquished responsibility for the NHS relinquishes hope for future health and social security for all.

This should make us wonder whether the social drivers of healthcare are changing. Foucault claimed health surveillance arose out of a mixture of State nationalism, to ensure survival of the labor force to create profit for the employers, concern for racial purity, security against the dirty and immoral pollutants etc, as an exercise in governmental biopolitics of population security through an entrepreneurship of the self.
But the State is being rolled back, the TTIP Transatlantic Trade and Investment Partnership provides the global market  with all the power.

In the meanwhile there is still a  rhetoric of austerity still fuels a governmentality of biopolitics that seeks to exclude the immoral pollutants by vilifying the immigrant with HIV (Farage and UKIP), the parent of the unvaccinated child (Abbot, Australia) and the obese addict (Duncan-Smith UK Tory).  These austerity induced discourses that rhetorically protect the ‘hard working nativist tax payer’ whilst setting working classes agaInst the unemployed and diverts attention away from tackling inequalities and the evident continuing ability of the rich to make surplus profits.  There is a market induced fetish for healthcare as a marketized commodity.
Under free enterprise the NHS will wither, the numbers uninsured will increase, healthcare will become a marker of individual wealth and individualised supremacy and superiority.  This is being accompanied by a changing subjectivity of lost souls with a modern day existential angst concretised by a fetish for a life that must be made to live by the individual in a frenzy of repetitive feeding orgies of self consumption through more and more medical investigations aided and abetted by the insecure medical expert desperately legitimising his status as expert whilst, just as existentially angst ridden as the patients, scrabbles around for his decision analyses and theories of probabilistic reasoning whilst ordering more and more tests. The experts call for less demand for unnecessary healthcare whilst watching the Government dismantle the one collective protective force against the market. Fiddling whilst watching Rome burn.  In the market the medical experts role is to provide the weakened cannon fodder for the market of ‘more tests’ by probing and prodding with the stilettos of the matador torturing the bull, the prepared patient/test-consumer.
The wealthy health-insured, will seek more and more second opinions, more molecular genetic fingerprinting, more expensive marque there will be more and more marqueés of ‘material success’, amputations and disfigurement, and continuing unhappiness. Oh Joy!

A perverse logic of normality is consuming us

An account of Derrida’s and Johnson’s deconstruction and the concept of the frame in relation to modern medicine and the logic of normality: 

In The Purveyor of Truth – a collection of writings, Derrdia critiques Lacan’s seminar on The Purloined Letter by Edgar Allan Poe. And Johnson critiques them both. Literature is described, and analysis of literature deconstructed. The description of ‘writing’ problematises the interpretation of writing, examines the potential multiplicity of significations that disseminate from writing, and concludes that to describe mandates an enframing that is paradoxically also impossible. I describe the way a signifier ‘normal’ functions in society and medicine using these ideas. 

Biological normality is an enframing social construct and a discursive practice that by being both mandatory and impossible enables powers to create categories of pathological tissue or madness or amorality that can be infinitely expanded and incessantly sacrificed and consumed as the hyper-precarious patient comes into contact with the jouissance of the medical expert in the perverse sado-masochist torture chamber of unfettered capitalism.

Cells multiply through the replication of DNA, a very lot of times all the time, and occasionally the reproduction goes wrong, and mutation occurs and dis-ease results. Why would it go wrong? Research suggests it seems to go wrong at a rate proportional to the rate of multiplication, and this accounts for two thirds of cancers, random errors in the DNA replication process. Any repetitive transcription of information may be prone to random error, I guess, but to say this isn’t to explain why. Nonetheless, this evident error proneness explains some dis-ease and even underpins the ageing process and death. I won’t say normal ageing process, because ‘normal’ isn’t the same as natural and is anything unnatural anyway? 

NORMALITY is an unanswerable aporia – a Kantian antinomy, but this doesn’t stop it functioning like a powerful  signifier with concrete material effects. The normal-pathological opposition is a duality that does not represent two independent wholes, instead a third term is created, a remainder, an inbetween-ness. Is this the failure of the Hegelian dialectical synthesis, instead both simultaneously normal and pathological and neither? Given the negative entropy of the universe what can normality mean? If we cannot define normality, can we define health, or healthy in terms of tissue representations? Something might be said to ‘look healthy’ which might say more about the limits of seeing, than about the nature of the tissue. If we cannot define healthy tissue in terms of appearance this implies we can never be sure if the said tissue which ‘looks healthy’ is unhealthy or pathological. Therefore population screening of asymptomatic tissue will always yield anxiety provoking borderline uninterpretable appearances and at the borderline there will be a naming-fest. (as exemplified by the numerous names given to borderline tissue representations in breast cancer screening)

It can be predicted that in an age of precarity and the sado-masochistic torture chamber of capitalism that human capital will be consumed at an ever faster rate, disseminating more selfish monistic (h)self-flesh to be consumed even as it is itself being consumed by itself.

Normality is a human construct like space and time, so there is perhaps a logic of normality, that might be thought of as just as paradoxical as Derrida’s framing (as described in The Purveyor of Truth in relation to writing and literature), whereby as noted in Johnson’s chapter in the same text, normality as a framing  is mandatory and impossible at the same time. I am applying these ideas of deconstruction here to a biological social field or a field of bio-politics. Is such an application also enframing?

Be Normal! is the injunction of Modern Healthcare as previously noted, the injunction mandated by e.g. the UK policy to have a national population based breast cancer screening programme. Be Normal! may be the injunction mandated by the sanctions threatened for those obese, alcoholic and Heroin addicted people who fail to attend ‘treatment’ programmes, or for the parents who do not have their children vaccinated.

Normality requires a definable identifiable objective – it could be said that we’re all normal all the time no matter what, but this is saying no more than we exist as Beings, not very helpful. The logic of normality for medicine is part of the logic of seeing, and what we experience (by seeing) of the ‘is’ of ‘what is” is different from ‘what-is’ by precisely what we see, this is Heidegger’s ontological difference.

Foucault might argue that ‘ Biological Normality’, historically is a social construct that enables Power to be exercised over those that threaten Power by enabling them to be defined against a norm e.g. as ‘indecent’ or ‘amoral’ or ‘high-risk’. Vague generalisations that can be applied by the powerful to all, at will, maintaining and reproducing the power of the already powerful. Canguilhem, one of Foucault’s teachers argued that Error is the mark of Life, but this may also be to enframe Life as ‘random error’, enframing the unframeable.

The perversion and accelerating self consumption and production of flesh by capitalism requires an ever decreasing threshold for pathological dia-gnosis, even to the point of pre-empting the diagnosis of current ‘pathological’ tissue through crystal ball future-telling genetic predictive screening creating pre-vivors. Even without genetic screening however, the threshold is being driven downwards downwards.

Illness, like child sexual abuse, demands detection/help/treatment/prevention to ease suffering and exploitation. The naming process demands an opposition between normal childhood experiences and non-illness, these in turn lead to unenframeable potential demonisation of the ‘abnormal’ : a vague and moveable/expandable human-catchment, the size of the fishing nets expands as the powers that be, always feeling threatened, demand more control over the lives of the population.

The sado-masochism of Capitalism and the addicted Subject-of-Precarity

Heroin Assisted Treatment (HAT)

HAT is ‘Heroin Assisted Treatment’, setting up supervised clinics where addicts can self inject Heroin that is prescribed. A recent BMJ article (ref 1) explains the evidence in favour of this ‘treatment’ benefiting those that have been ‘refractory’ to help with oral substitutes such as Methadone and accompanying psycho-social supports (e.g. Counselling for anxiety, stress, PTSD; and help with housing, debt management; and access to group work with people who have overcome a substance addiction – called Mutual Aid).

Implementation of HAT will be politically unacceptable under Capitalism

This account explores the problems of implementing such treatments within the culture of capitalism and a neoliberal de-regulated free market where ‘anything goes’. From a psychoanalytic perspective such de-regulation has caused a structure of the social-economy to emerge that is one of perversion, where the individual is now de-humanised ‘human capital’ that self consumes through consuming objects ”of pleasure’. (Ref 2)  Such objects include the ‘medical test or treatment’. The administrators of such a culture – governing or sham-governing act like sadistic torturers – cycling between a) promising relief and b) blackmailing with pain. These elements are applied to the problem of HAT and its implementation.

Implementation is unlikely in a failed market based healthcare system.

Whilst the trial evidence in terms of societal costs and health benefits seems fairly solid in favour of Heroin Assisted Treatments for the ‘refractory and suffering addict’ the possibility of implementation faces a huge political barrier. The influential think tank ‘The Centre for Social Justice’ headed up by government minister Ian Duncan-Smith published ‘No Quick Fix’ in 2013 – this prepared the ground for Conservative policies to impose benefit sanctions on addicts (Heroin, Alcohol, even the Obese) who ‘refuse’ to access treatment. The report likens Methadone to providing vodka to an alcoholic instead of his preferred gin and tonic, and suggests sanctions and withdrawal of Methadone may, through the break up of families, homelessness and emotional breakdown, actually encourage engagement with treatment and ultimately, abstinence.

“Much of the system’s response to addiction remains to supply methadone to heroin addicts, a policy akin to supplying an alcoholic with vodka in place of his preferred gin. Methadone is an opioid (artificial opiate) invented in Germany which mimics some of the effects of heroin but without the ‘highs’. However, many abuse it, with some addicts selling their prescription to other addicts. It is a legal class A drug supplied to addicts through the public purse.” (p27)

“The CSJ has heard, however, that current reforms to the welfare system may be drawing a previously hard-to-reach group of addicts into treatment. For some addicts, a ‘nudge’ is required before they seek treatment. This can be the negative effects upon their own health, getting arrested, or the prospect of losing their children. The CSJ has also heard that for some who had refused treatment before, reforms to the welfare system under the current Government have led them to come forward for help with their addiction.” (p53)

This rhetoric of ‘abstinence’ or refusal of treatment is filtering into clinical work as substance use services are competing for tenders and cutting costs drastically.  The likelihood of implementation of Heroin Assisted Treatment seems light years away.

The political move to the right and repressive attitudes to addicts is fuelled by the financial crisis and austerity. The market economic system has failed and leads to health inequalities.  The addict is just one example of a subject compulsively ‘enjoyed’ by a market system based upon a discourse of self-sacrifice and the always failing satisfaction of chasing profit for profit’s sake. There is no longer any pretence of achieving social security for all.  The chances of HAT being implemented may require a revolution in our political- economic system first.

Childhood Vaccinations in Australia

Another example of bio-politics in action is the recent announcement that the Australian government is planning to withhold welfare payments from families that do not have their children vaccinated.</

The prime minister said that his government was “extremely concerned” about the risks posed to the rest of the population by families who chose not to immunise their children.
“The choice… is not supported by public policy or medical research nor should such action be supported by taxpayers in the form of child care payments,” Mr Abbott said in a joint statement with Social Services Minister Scott Morrison.

Again we have a ‘threat’ demonising a section of the population, ‘people who choose not to vaccinate their children’,  and a sanction to protect ‘the taxpayer’. This is a bio-political act as with the intended plan in the UK to sanction addicts who fail to complete or access ‘treatments’ (and become abstinent).  People are positioned as those who ‘must’ comply. A condition for being valued as a citizen opens you to blackmail, and this is justified in terms of the vague universal ‘threat’ you may pose, and in times of imposed austerity is framed as being especially justifiable in terms of being fair to the ‘taxpayer’.  A parent’s  choice for their child is now being managed by the state and The Law. Does the State feel free to do this because it is no longer restrained  –  the permanent crisis of capitalism, with the resultant evaporation of any prohibitions on State actions, leads to a need or drive for the state to ‘enjoy’ its citizens through mechanisms of promised ‘protection’ alongside sadistic punishments in the name of ‘necessary austerity. This becomes medical fascism.

It is possible to argue that medical interventions ….. are part of a structure like a see-saw – and always susceptible to the drives of a capitalist system that is always in crisis and is currently reacting to the 2008 financial crash with a rhetoric of austerity. See sawing between a rhetoric of credit and debt. Two opposing activities are taking place concurrently : and both act upon this object’s ‘access to medical investigations and treatment’: the drive is structured like a Lacanian structure of perversion wherein the subject has become ‘free’ as the master has evaporated into thin air, as the failure of capitalism has become apparent – especially given the Troika’s intransigence in relation to Greece’s permanent indebtedness.  Thus access to medical investigations and treatment has become the object of enjoyment for its own sake, any ‘test’ will do. The pleasure (beyond that which will provide for physical survival) is the jouissance obtainable through providing the other with access to (and controlling) their access to jouissance. Thus, as with the sadist, of perversion, the subject the medical-technician has the Other, the ‘patient embodying the flesh to be tested, treated, (and sacrificed) has the patient at the mercy of his whims – jouissance is obtainable  (for the medical-technician) by offering access to medical care: suggestive of a) offering ‘prevention of pain’,  even at the same time as b) blackmailing the patient as a way of limiting access and causing pain.

This is line with the perverse structure of capitalism where ‘anything’ can be interchangeably needed enjoyed and used for the ‘flesh’ or ‘flash’ of jouissance it provides but nothing is desired for its own sake, for the promise of its desire for the subject. A horrible example might be the man ‘with everything’ who no longer desires love through the love of the other, but instead transgresses, and having lost his master and castration, is now driven by the need to ‘use’ or ‘enjoy’ prostitutes, or voyeurism or sadism and so on.


It is imaginable that such a man – too close to the object of enjoyment – becomes so free of any law that he makes his own law, as a banker selling high risk debts to the vulnerable, a pharmaceutical dealer hiding unfavourable trial results, or even a surgeon such as Ian Paterson assaulting healthy women with unnecessary breast excisions and perfecting inadequate excisions on women with breast cancer.


Drug users should be able to get heroin from the health system

  1. Martin T Schechter, professor, School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, Canada

2. Lacan and Debt, by Andrea Mura

LAND OF STORMS : a film of young gay love, homophobia and murder. An alternative review. 

directed by Ádám Csász

Following a showing of the film at the Brody film club in Budapest recently the director, Àdàm Csàsz, told a few of us that the film was based on a true story and he elaborated this with a description of the alleged killer’s subsequent (i.e. after the end of the film’s storyline) police investigation, trial, confession and imprisonment. But it sounds too good and too convenient  to be true. “Based on a true story”, the director says,  but Is the story true or just another imaginary fiction that’s sustains homophobia? Who was the murderer really? Was it his lover in a fit of temporary insanity brought on by the impossibility of reconciling the double bind of homosexual love with being an accepted member of his homophobic village community? Or was it a homophobic blood lust by an other, reflecting a State legitimising its authoritarian  strategies through homophobic victimisation. 
The film portrays the development of young homosexual love in rural Hungary, the victimisation of the lovers by the rural community, and ultimately tragically the killing of one of the young boys by the other. Said to be based on a true story it is said the young homosexual lover did eventually confess, was found guilty,  and is currently still serving a prison sentence. 
The film stands as it is and this commentary is not to suggest alternatives or improvements on it but to reflect on other possible truths than the apparent ‘true story’. The ‘true story’ as portrayed by the director, in conversation with us after a showing of the film in Budapest in March 2015, is that at the end of the film Aron the young teenage Hungarian stonemason from the village murders his equally young lover, the (ex) German footballer, and runs away across the fields. Àdàm Csàsz the directors tells us that he was drawn to this tale when he heard of a
grisly murder that involved a love triangle of three boys, clearly a homosexual love triangle ending in death, his researches revealed a trial in which the young Aron initially refused to confess, Àdàm maintains he is convinced of Aron’s guilt because of the opinions of forensic psychiatrists (who also decided Aaron was sane at the time of the killing as well), despite there being no hard evidence. The actual murder was much more brutal than in the film. The victim is hacked to pieces with an axe and burnt in his house.
One could argue that the film could have left the identity of the murderer open to question. There were others with motives.  We are also entitled to doubt the confession and guilty verdict.  There may have been political pressure to ensure Aron is found guilty since this is then an inter-homosexual killing and not a homophobic killing which if publicised would embarrass the state.  I think one can argue that by going along with the guilty verdict the film, perhaps unwittingly, ultimately provides support for the State’s disavowal of the existence of homophobia and misses a further opportunity to challenge and resist it.  An enigmatic ending in which possible murderers include the homophobic footballers father, or the girlfriend’s brother might have been a more potent portrayal of the Real of the horror of homophobic hatred.  Àdàm told us that Bernard the other German lover was initially a police suspect but had an alibi having left the country before the murder.  
An interesting theme here is that of “confession” and in particular Aron’s confession, Aron had, in the film, failed to get his mother to directly confess to betraying his confidences leading to his victimisation by the community.  Aron’s confession reminds me of Foucalt’s story “Moi, Pierre Rivière” and the confession of the slaughter of Pierre’s  mother, his sister and his brother in 1835. A tale of psychopathology, the law and community.  Subsequently made into a film directed by René Allio in 1975. For Foucault confession is important as it legitimises the States power as well as cleansing the State functionaries of any personal guilt.  The killing also reminds me of Freud’s case of the psychosis of Daniel Schreber a high court judge who became psychotic in the 1800s and wrote his memoirs of his illness. Freud attributed the illness to a repressed homosexuality, Santner in his book : “My own private Germany” attributes Schreber’s psychotic illness to a crisis of investiture as Schreber fails to cope with the status and power of becoming a high court judge and his psychic traumas and development subsequently reflect the States misogynism and anti-semitism. By extension if Aaron did kill his lover was this the result of his own crisis of investiture as a homosexual by his lover and did the murder reflect the State’s disavowed strategy desire to rid itself of (if not actually murder) homosexuals? And if so could be considered to have suffered a temporary psychotic illness when he killed his lover which might also explain to a degree then brutal nature of the real killing, downplayed in the film. 


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:

“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.