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Why asymptomatic medical diagnostic screening should be stopped

The USA audience may be even more smitten by the assumption of sovereign individualism than the UK. The scientific-technological relationship to consumerism and individual choice touches on matters of life and death when it comes to asymptomatic medical diagnostic screening programmes such as, most notably, the breast cancer screening programmes. These have been challenged on evidential scientific grounds by such reputable figures as Michael Baum who has called for such screening to be stopped (ref). Perhaps some may be surprised that such challenges have met with such little response – indeed the programmes are being extended to wider age groups rather than reduced. One of the foundations of medical ethics is the idea of freedom of choice for the individual. And rightly so. And a lot of work (including by me in the past) has gone into trying to maximize patient autonomy over decision making by ensuring information given is as user friendly and unbiased as possible. And rightly so.

However, and this is the crux. The premise of these efforts is that proactively offering the screening intervention is a good thing. UK government sponsored ‘Independent’ reviews have concluded, because a) they show that screening reduces specific cancer deaths; and b) that the harms, including overdiagnosis, are known about and quantifiable and therefore can be communicated to the public, that (breast cancer) screening is a good thing. And in general this has been the thinking for most non-targeted asymptomatic anticipatory diagnostic screening.

Just here I will make a small diversion to consider over diagnosis, as an unusual type of harm that perversely is used to promote screening, and yet confuses many, and cannot be adequately valued by many individuals for the harm that it is.

Overdiagnosis / this concept deserves some attention.

First, because knowledge and quantification of overdiagnosis is, somewhat counter-intuitively, used as justification for continuing with proactive screening programmes. (This is on the ground that as long as the public are told ‘the facts’ then people will be free and able to make their own kind up about whether to accept ‘invitations’ (read as compelling demands) to be screened). Of course, life is more complicated than that, and over-diagnosis certainly is. There are two things to know about the concept of over-diagnosis: the first is that it is due to the (necessary) failure of technology to identify a clear distinct borderline between bodily functions/tissues that are ‘normal’ – in the sense that the tissue will not become pathological (literally, cause suffering) and ‘abnormal’ – tissue that is predicative of, (assures with certainty) a symptomatic pathological future. This is because at the borderline the futures of these visually ambiguous and borderline bodily functions and tissues are under the unpredictable whim of random molecular processes. What looks to have carcinogenic potential is just as likely to have an asymptomatic future. This means that asymptomatic screening must always run into misdiagnosis at the frontier between the normal and the pathological. This failure leads to diagnoses of future symptomatic cancer that are simply wrong, a mis-diagnosis. This is overdiagnosis and leads to over and unnecessary treatment causing net harm to health.

Second, note that overdiagnosis as a phenomenon can only be inferred from the comparison of cancer diagnoses and symptomatic cancer outcomes between screened and non screened groups. In this sense whilst it is real enough it is also as far as any personal experience is concerned, an abstract concept. This is how public health policy makers can get away with not valuing the scale of over-diagnosis in calculations considering whether screening is a good thing (because no individual can stand up and say “Look, I’ve been over diagnosed and had an unnecessary mastectomy!”). This renders over-diagnosis a strange non-valuable, in a healthcare sense, (though profitable) harm as far as the market and its tool: pragmatic public health policy, is concerned. This, in turn, also means that for many (not all) individuals over diagnosis is a confusing concept that cannot adequately be taken into account when making decisions. Of course, for some the knowledge of the existence of overdiagnosis can be sufficient to lead to a refusal to be screened, or anger if insufficient information on over-diagnosis was made available at the time screening was being ‘offered’. This is a digression into the idea of over-diagnosis, that isn’t necessarily a deal-breaker as far as screening is concerned, but in my view adds to the reasons why asymptomatic non-targeted screening should be stopped. The main reason, as elaborated below, being its fundamentally and effectively anti-democratic and coercive nature as a fear inciting commodity in an uncaring free market dominated by capitalism’s demands for new and surplus profits.

So, now, bearing in mind the phenomenon of over-diagnosis as an especially elusive and malevolent kind of harm, we can return to the key questions for screening programmes.

First, what if there was genuine uncertainty about the overall benefits of such screening programmes, in terms of their ability to reduce overall all-cause mortality. After all, Baum has convincingly argued that both plausibly and evidentially, screening and treatment both can cause harm, including deaths, in their own right, and this is why overall mortality reduction due to cancer screening has not been demonstrated.

Second, what if the first principle of care should be to maximize patient autonomy over and above the targeted reduction in specific cancer deaths?

And, third, what if it could be demonstrated that even the proactive offer of such screening fatally undermines patient autonomy?

My argument now follows and combines the lines of thought of both Karl Marx and Jacques Lacan the French psychoanalyst. The key issue to keep an eye on here is the implication for individual freedom of choice.

For Marx, the capitalist system of waged employment to generate surplus value (profits) for business owners, manages to mystify and make invisible the lack of freedom for the worker (who MUST work to live), whose labour is effectively forced from him, stolen and used to generate value of our production that exceeds the cost of wages. This mystification of the exploitation of labour makes it seem as if profits can generated as if requiring virtually no effort at all on the part of the business owners, other than to employ people. Clearly a simple view but essentially true nonetheless.

This gets even more interesting when we introduce a psychoanalytic perspective. Following Lacan, then, who followed Freud: three key things: first, our individual sense of identity, our Ego, is formed within and constrained by cultural norms; second, this sense of identity is always only ever partial, creating a desire to either question, or please our cultural masters; and third, the capitalist system has profoundly affected the cultural Master and its norms – by creating a capitalist/consumerist culture capitalism has largely replaced culturally generated norms with the idea of surplus value itself. This has disrupted the sense of identity held in common by the masses so that we are predominantly driven by the desire for more, always expressly hungry for more and always more or less dissatisfied with what we have. We become the puppets of the system, of the market and advertisers who in turn are also controlled, and turned into mechanical tools of the system which demands competition, winners and losers, and ignores human suffering. This system also exploits the imaginary certainties of the mechanical utopian philosophies of science and the subject of science who is taken to be fully self aware, to have a whole unitary unassailable identity as a sovereign individual in control of his own decision-making and destiny.

The combination of a) the objectivisation of the human into a mechanism to exploit human and natural labour for the bottomless pit of human desire for more; b) the psychologisation of the human as a unitary autonomous atomic sovereign individual by neuron and psychological sciences; and c) the assumption that science can know the truth about nature including human ‘nature’ and the body’s future, all combine to incite the production of a totalitarian perverse psyche over-excited by the fantasy of being in control, of being the one to win, to own, to beat and to conquer the other losers, foreigners, competition, victims. This is brutally xenophobic and exploited by populist nationalist elitist and racist politics.

Unfortunately medical practice has been profoundly damaged by these processes. The result is that what seems like a philanthropic well-meaning offer to test the asymptomatic for signs of anticipated future disease and all that goes with that, has become a tool of capitalist, nationalist and apparently pragmatic business philosophies. But at the time has involved the oppressive exploitation of the consumerist desires and guilt of the masses using fear of future disease, the promises of more (surplus) life, of more (surplus) time with loved ones and so on.

Simply put then, in the end, given the equipoise over therapeutic benefit (let alone all-cause mortality reduction), the unavoidable and profound bias invoked by offers to screen, the in-sensible invisible nature of over-diagnosis, and the primacy of democratizing decision making to maximize autonomy; then the most ‘ethical’ way forward (that does the least harm) is to stop offering non-targeted asymptomatic anticipatory diagnostic screening. There should be a moratorium; debate over how or whether to target screening to high risk groups and whether it is medically unacceptably unethical to agree to screen somebody not at increased risk of disease.

This is clearly an authoritarian stance, but a lesser of two evils, as it is, I claim, less authoritarian than exposing the masses to the fear induced exploitative provocation of proactive asymptomatic anticipatory diagnostic screening programmes.


The account above is an intervention that creates a new and disruptive discourse around asymptomatic diagnostic screening. It is a critique from the perspective on the human whose essence is one of a lack of a complete sense of individual identity constructed within normative cultural constraints and has taken three factors into account: a) effective truth, exercised by b) political power, to create c) an ethos or ethics of pragmatic action in the name of targets productive of surplus-value. It does not claim to be promoting a good of some kind, but rather to be promoting a lesser evil.

The context for the intervention is the culture of deregulated capitalism. The ethics discussed apply to an intervention affecting individual rather than social or communitarian health outcomes, for example screening for things like cancers, hypertension, coronary artery disease risk, diabetes, depression etc. So, one caveat is that my argument does not extend to asymptomatic diagnostic screening for infectious conditions – such as Covid. This is because in this case an argument can be made for encouraging individual sacrifice (for example, in terms of freedom of movement and socialization) for the sake of, or in order to protect, vulnerable members of the community.

Identifying with or following the law: the totalitarian psyche and the extraordinary slaves

As a rule self-sense is constituted via the imagined demand of a Big Other to follow the Big Other’s (or symbolic Father’s) Law. This constitution involves what in psychoanalytic terms is called castration. It enables the individual to achieve a degree of stability for identity and to be able to repress his knowledge that in reality, at base, he is without identity: a subjective void.

As a rule one follows the law, but as Vadolas has suggested it may be possible for some, with a totalitarian psyche, to identify with the law

To identify with the Law: is to think that one’s self, in one’s being, IS the Law, and this excludes the role of the imagined (lacking) Other/Father/Master in constructing the sense of self or identity.

But when this Law is fascist/sociopathic, is decreed by a Master of Fascism (the ‘ideal-type’ narcissist), then identification with this law produces the Totalitarian psyche. What’s at stake here is a) following a Law, versus b) being that Law.

Two questions:

1. What is the implication for the discourse structure for the individual – in the social context where this Law has effects?

2. Is this the same for the perverse narcissistic psyche?

To BE the Law, and to reject castration, (is to confront the death drive and it’s void and the danger of the (m)other). This isn’t a simple perversion as it were (if this isn’t a misnomer) because the totalitarian psyche is given the Law to follow – he is a follower. He does not make the Law up for himself. He may believe his thoughts to be as good as empirical evidence for determining particular effective truths and therefore for determining actions to serve those truths – that is, he may be a radical empiricist/pragmatist.

Whilst there may be classical slaves for totalitarianism, those who are uneasy but still obey the totalitarian law; conversely the totalitarian psyche may have a perverse psyche that identifies with the Totalitarian Master’s Law and could be described as an extraordinary-slave. These totalitarian followers or extraordinary slaves of totalitarianism would be the ones that appears to have no doubt or uneasiness, to be dogmatic and certain and over zealous, to always go a destructive step further and always seem to ‘enjoy’ destruction and for destruction to spur them on to even great destruction. I don’t know if this level of extremism is a rarity or not. This psyche does not think but only is. He is where he does not think, as Lacan pointed out. This means he is not amenable to reason or argument, and (perhaps like the psychotic) may not be analyzable. Imagination does not play a role in the constitution of his psyche. Classically the Law he follows consists of extreme levels of destructive racism, ultra-nationalism, patriotism and/or religiosity.

The Master-Fascist may, perhaps, NOT be a perverse narcissist. But also may be. He may also be a libidinal, classical, Master

Who or what demands war?

In this tweet,

related to this very interesting article from 2014:

Mr Peter Hitchens refers to ‘certain utopians’ wishing to create war in Europe today, 2022:

This seems to speak to the question of the causes behind the escalating war in Europe today, 2022. I argue here that by laying the blame at the door of ‘certain utopians’ he leaves something out? I suggest that the key driver for the creation of war today is an out of control capitalism that has both a) given Fascist Masters power; and b) captured the social psyche: creating a self-destructive narcisssitic perverse monster.

Whilst he (justifiably and importantly) implies human choice and agency, albeit of a utopian kind, he doesn’t mention the systemic causes driving the drift to extreme right-wing politics and the demand for more war.

This systemic cause is, (following Marx and Lacan), capitalism and its incitement to limitless barbarism and the totalitarian social psyche. This incitement operates through the irresistible lure of surplus-value (of many kinds including financial, but more of everything), as if for free, an illusion offered by the capitalist model of the exploitation of waged Labour, that triggers a radical shift in the operation of the psyche into an unbearable narcissism.

This narcissistic turn in the masses, conditions the masses to accept, and even desire and find a kind of pleasure in, the hate-speech used by Fascist Masters (who abound in right-wing politics today) to incite hatred of all kinds.

This capitalist power and it’s supremacist arrogance demands violent surplus-value: more war and destruction of what is deemed an alien threat to ‘our way of life’. This destructive drive consummates and consumes (Mura), feeding the demand for an always de-compensating, hypertrophic and self-destructive libidinal excitement.

So what?

Doesn’t this mean that today, to be effective, any anti-war movement must also be anti-capitalism. It must act against capitalism and its reactionary progress towards self destruction. Even though this will lead to a continuing battle between left and right.

I have no confidence that an anti capitalist movement will succeed, I think things have gone too far. However, if mankind survives these cataclysmic times it feels better to speak out and resist the barbaric drives even if, like the Dissenters and Levellers we fail. The middle classes criticize but Fascist minded governments stop listening – this is not the sign of a happy society.

On Covid Vaccine Mandates 2022

In summary, I argue here that, perhaps surprisingly, Covid vaccine mandates, (laws, for example, that say health and care-home workers must be vaccinated in order to be allowed to do their work), are a thin end of a discriminatory and authoritarian wedge that open an ideological pathway to belief in the same kind of nationalist myths, promoted by Nazi Germany, that mandated enforced sterilization, and euthanasia of the elderly and disabled in the 1930s.


In the UK, and in other countries during 2021, there has been a push for Covid vaccines to be mandatory for staff in health and care settings.

On the one hand, some argue Covid vaccine mandates would protect vulnerable patients and care home residents, while others argue such a government imposed mandate would breach a long standing public health, ethical, stance, that respects individual autonomy over personal bodily interventions that involve personal risk. At the moment such a mandate is not being put into practice in the UK, although the policy is still under review and may change, but in some countries, such as Austria, there is now such a mandate.

To begin with we should try to clarify two things: a) the difference between freedom of speech and freedom to act upon self or others; and b) regarding bodily autonomy, the difference in terms of the body’s internal workings as distinct from the body’s actions on the external world.


So, first, we need to be clear on the difference between a freedom to express a view (free speech) as contra-posed to a freedom to discriminate against others through actions. The latter is a form of xenophobia (an example is provided below) that incites hateful violence against minority groups.

Second, we also need to bear in mind the difference between personal bodily autonomy vis à vis the internal workings of one’s body as contra-posed to a bodily autonomy that refers to actions taken by that body, for example, behaviours such as seat-belt wearing.

Bodily autonomy

For adults: “Bodily” means anything that involves the internal workings of the body that affects personal health (in Canguihelm’s sense – the ability to maximize potential for functioning) and the idea of “autonomy” as used here refers to something that is as a result of a personal decision.

Of course the idea of personal decision making is problematic as we are, and our imaginary identities are, an amalgam of personal vs cultural identities. But I won’t explore this further here.

The idea of “bodily” here, is limited to its internal workings and excludes its (the body’s) material actions on the external world (eg fighting) whilst recognizing that, for example, taking anabolic steroids, a personal bodily decision, affects the metabolism and personal health AND may lead to aggressive behaviour towards others, a social action.

Vaccine Mandates

In summary, to reiterate, such mandates are a thin end of a wedge that opens an ideological path to belief in the same kind of nationalist myths held by Nazi Germany that mandated enforced sterilization and euthanasia of the elderly and disabled.

I argue that where there is personal risk of harm from vaccines. involved there should be a red line for medicine: this is because preventive interventions always carry risk of harms that cannot be valued adequately, such as over-treatment (and for tests, over-diagnosis), they are over-sold/hyped leading to fear which incites desire felt as an imperative demand, whilst generating surplus profit and power.

Bodily autonomy and Ideology:

An example

The following example is intended to illustrate how confusing free speech with freedoms to act socially highlights how vaccine mandates are a freedom to act socially that discriminates against a social grouping. In the case of vaccine mandates what is at stake is a) the freedom to have a personal belief; and b) autonomy over decision making with respect to the body itself.

Fundamentalist Christian groups follow a socialized normative belief that claims homosexuality is a sin. Followers of this ideology have tried to weaponise the principle of free speech in order to legitimize discrimination against gays on the basis, NOT of speech, but of actions, namely a refusal to sell or serve gays in shops.

A case in point is where gays were refused service by a baker to buy a wedding cake in a Christian evangelists cake shop because the owner believes their sexuality is a sin.

The court ruled in favor of the Christian fundamentalists but ONLY on narrow technical grounds (insufficient impartiality on part of the commission ruling the bakers actions unlawful).

The court arguing:

“any decision in favor of the baker would have to be sufficiently constrained, lest all purveyors of goods and services who object to gay marriages for moral and religious reasons in effect be allowed to put up signs say­ing ‘no goods or services will be sold if they will be used for gay marriages,’ something that would impose a serious stigma on gay persons.”

I suggest that any apparent “Free speech” that expresses discrimination against personal choice re bodily autonomy should be against the law as it amounts to socialized discrimination on the basis of personal belief of the ‘other’. It’s a tactic to claim this is a freedom of choice for the owner of the store; just as it is a tactic to claim that vaccine mandates is a form of freedom for the vulnerable in health and care settings. When, in fact, it’s is a form of universalized social discrimination – to refuse work to somebody on the basis of their beliefs or lifestyle. .

The argument that the unvaccinated pose a risk to the vulnerable in care fails when a) it is known that even the vaccinated have waning immunity and can be re infected, and b) more importantly, the primacy of personal bodily autonomy protects us all, even the vulnerable – and remember the vulnerable under Nazi-style fascism suffered enforced sterilizations and euthanasia. This is an extreme example but illustrates why vaccine mandates should be a red line the health and caring professions should not cross.

UK-State propaganda: Foreign Tryanny, ‘whataboutery’, and anti-capitalism

“Arthur Li, the chair of @HKUniversity Executive Council told @BBCNewshour that he cannot call the Tiananmen “events” a massacre because he wasn’t there to verify it. I assume, by the same logic, that he cannot call the Nanjing “events” a massacre either? Beijing’s trumpet”


A tweet 23/12/2021 by an associate director of RUSI (UK’s Royal United Services Institute).

This short blog was written before Russia invaded China. It is prescient in the sense that it already warns us of the west’s sophistry and hypocrisy when it comes to manipulating reality in order to massage public sentiment with false but effective truths. It reveals the cycle of mutual antagonism caused by these lies, and the failure to acknowledge and value these as harmful to global (and therefore western) security. I am not an expert on geopolitics or international relations but I can see the lies covering the west’s imperial and criminal past and present in the way it supports regimes like Israel and Saudi Arabia. And I can see how these sustain the cycle of antagonism leading to more violence. The manipulation of historical realities to whitewash western crimes is in itself anti-democratic – it manipulates the representation of political values and deceives the meanings and sense held-in-common by the masses.

In short, a comment by a senior security think tank executive accused a politician of being deceitful about the truth of the massacre of Tianneman Square. And accused the politicians of being a trumpet for Beijing. Of course we should know the truth of the massacre. However, at the same time such think tank executives act as trumpets for, for example, Saudi Arabia and Israel, by covering up their massacres, by being silent about them and by encouraging them with the supply of money and arms. To point this out leads to accusations of ‘whataboutery’ as an attempt to point to a ‘as if’ disconnected observation to discredit the speaker as it were.

However I suggest that so-called ‘whataboutery’ is an important and relevant observation signaling the need to admit the anti-democratic and dangerous manipulations of truth being exercised by the Western powers and that these are in themselves a danger to global security.

So, to return to my response to the above tweet.

Subsequently, when I pointed out that similar criticisms could be made of other regimes that attempt to erase massacres or genocides from history, such as Turkey and the Armenian genocide, and Israel and the Nakba, for example see “Burying the Nakba: How Israel Systematically Hides Evidence of 1948 Expulsion of Arabs” this was effectively dismissed and characterized by Eyal as ‘whataboutery’.

But, I suggest, this point would only be ‘whataboutery’ if the original critic is also just as willing to critique these other revisionists. It seems pretty clear from the analyses I cite and arguments I produce below that my point is not ‘whataboutery’ because there is a political bias within the western establishment and its security advisors.

For context RUSI’s “RUSI’s mission is to further independent debate on defence and security in the United Kingdom and across the wider world.”

This isn’t a critique of RUSI in general, but explores the potential implications of Eyal’s tweet for the way it addresses “defense and security”.

The implication I draw from this is based upon the failure of Eyal to acknowledge the sophistry of, for example, Israeli-zionist deniers of the Nakba (catastrophe) inflicted upon the indigenous Palestinian population by Jewish-zionist terrorists in the 1950s (aided and abetted by the British). It is only an implication but has more weight when past analysis of RUSI’s output is considered.

For example see: “Why is the BBC presenting RUSI as objective analysts of the Middle East?” From 2015. This analysis points to the importance of sensitivity to the way security debates are framed, how this framing may ensure a partisan state-sponsored outlook at the expense of objectivity, and of the harms being caused by military interventions by western ‘Allies’.

The implication, then, not surprisingly, is this: that a self-identified independent think tank on British security in reality does analyses from the perspective of the western powers and NATO. But why does this matter?

On a softer, less certain note, it is important to ask whether this kind of manipulation works to reduce rather than increase global security.

This matters: a) because it shows how so-called facts are being manufactured (as effective truths) by so-called liberal democracies to manipulate the mood, ‘atmospherics’ and public sentiment in order to ensure policies are publicly acceptable; and b) because the manipulation of truth, and of so-called ‘public sentiment’ is essentially anti-democratic. For example, it ensures public opinion, on things like the decision to attack Iraq, or to support Saudi military attacks in Yemen, is based on an unrepresentative, narrow and ultimately misleading perspective.

For example, support of a so-called western ally such as the Israeli-State, may serve to stimulate military aggression to undermine democracies globally, because Israel, despite its relatively small physical size, is a disproportionately powerful global marketeer of military technologies, as described in detail by Halper in his book: “War Against the People: Israel, the Palestinians and Global Pacification”.

So, there is a potential domestic threat to domestic security and democracy in the name of promoting western and global security.

This raises the question of the basis of contemporary geopolitical alliances and antagonism.

To what extent are these based on, for example, a) perceived threats from (selective) ideologies of failed-states or tyrannical (Islamic) regimes (but, contradictorily, not some others); or on b) a perceived need to ensure things like energy (oil, gas, electric) security that depends on other nation-states, including perceived antagonists (threats to energy security) such as Russia and China. How valid are the accepted truths of western security regimes under the banner of organizations such as NATO?

To what extent are these manufactured effective-truths self-fulfilling, because the inherent antagonisms assumed by those truths, and the biased manipulation of public sentiment, actually aggravate backsliding anti-democratic tendencies, and provoke aggression from other global actors.

The problem, of course, is that other nation-states practice the same self-fulfilling anti-democratic manipulations, provoking the same transnational aggressions. So we seem to be stuck in a cycle.

One solution, ultimately appears if we view most nation-state policy as driven by corporatism and the pursuit of effectively unregulated (at transnational or infra national levels) capitalism. This solution may be found, in the longer term, in current anti-capitalist trends.

To finish off then,: what is the most plausible explanation for the “whataboutism” response to my observation that historical revisionism has been practiced by many nation-states, including Israel with respect to the Nakba and not just China with respect to Tianneman square?

I would argue that the “whataboutery” response stems from, a possibly unconscious, awareness that RUSI’s culture is inherently biased towards western imperial expansionist intentions and targets, and itself practices sophistry and manipulates public opinion in anti-democratic ways. And, that this is itself a threat to global security.

False reassurance and Mass rapid testing for asymptomatic Coronavirus infection and infectiousness

This requires a little bit of background. The Johnson PM of the UK government announced a ‘moonshot’ programme, many months ago in September 2019, in which there would be mass daily screening for C19, for the asymptomatic, at a cost of over a billion UK pounds.

… literally millions of tests processed every single day … theatres and sports venues could test all audience members on the day and let in those with a negative result, all those who are not infectious … workplaces could be opened up to all those who test negative that morning and allow them to behave in a way that was normal before COVID … Our plan – this moonshot that I am describing – will require a giant, collaborative effort …

Today, January 2020, the government has begun and now ‘paused’ such a programme due to start in schools because of worries it may do more harm than good.

The key point is that despite doubts about the accuracy of the test and the risks of false negatives, the UK government has been persistent in wanting to roll this out, in order, it claims, to keep pupils in schools and ‘to keep the economy running’. Because of the inaccuracy of this rapid lateral flow ‘moonshot’ test and the collateral harms it will lead to, and I suggest that the UK government’s primary goal is to keep the economy running, even if, as is probable this will cause increased viral community transmission of C19.

Briefly, the test being used is a rapid ‘lateral flow’ test (Innova currently). It was shown in a Liverpool study to only pick up 50-60% of cases. The test is said to be 50-60% sensitive, and other studies suggest this may be an over-estimate. This means it misses 40% of cases, or in other 40 % of negative results will be false negatives.

A false positive result occurred in two of 2981 PCR negative people—a specificity of 99.93% (99.76% to 99.99%). But lateral flow tests missed 23 of the 45 PCR positive participants, giving a sensitivity of 48.89% (33.70% to 64.23%).

Covid-19: Lateral flow tests miss over half of cases, Liverpool pilot data show. BMJ 2020;371:m4848

This means that as many as 50% of people, (students returning to university, school children , or potential visitors to care homes) will be wrongly reassured that they are Covid negative. There have been calls from scientist, including Jon Deeks the co-chair of the Royal Statistical Society’s diagnostic tests group, as well as Gill and Muir-Gray for the government to urgently re-think its strategy.

Note, as well, that although the tests is highly specific – good at identifying positives correctly, this means that because the prevalence of true positivity is low in the general asymptomatic population, then even this high specificity still produces many false positives:

The false positive rate of 0.6% means that at the current prevalence in Liverpool, for every person found truly positive, at least one other may be wrongly required to self-isolate. As prevalence drops, this will become much worse.

In terms of the poor sensitivity and high false negative rates : the danger of having large numbers of people under-diagnosed occur when the negative result is used as a green light for social mixing (e.g. in schools) to continue, because this means that large numbers that are actually infectious will continue to mix, and, crucially, may mix in increasingly risky ways than if they hadn’t had a test at all. At the same time, although many true positives can be told to self-isolate reducing social transmission, all the same this benefit may be outweighed if those testing negative behave as if they are really disease free when they are not, in ways that increase risks of transmission.

In other words, false reassurance may well lead to increasing risky behaviours, rather than just having no effect at all on the risk of transmission compared to the situation where no testing had been done.  In other words, the key question is: What is the net effect on transmission rates of testing compared to no testing?

Understandably some scientists are asking for real world empirical studies to find an answer, but there are no signs of such studies forthcoming, and no doubt they would be difficult to do and interpret, given potential confounders and rapidly changing social circumstances and regulations.

Some have argued that the worries about false reassurance increasing risky behaviours isn’t borne out because, for example, the introduction of seat-belts, and cycle helmets etc. didn’t lead to increasingly risky behaviours. I think that this comparison is invalid for four reasons:

a) The test signifies ‘freedom from danger to others’, a freedom from a need to be careful, from guilt or vulnerability, whereas the hat/belt signifies reduced, but not zero, personal risk but, rather, is a continued concrete physically present, and sensed, empirical reminder of vulnerability;

b) Unpredictably, people may or may not want, or value, a negative result and will tend to believe or not believe it depending upon either, for example, they experience : (i) levels of fear of the disease or fear of loss of income if told to self-isolate; or conversely (ii) a lack of fear of the disease and possible value from secondary gains from a negative result due to, for example, avoiding stresses by being permitted or told to take time away from work or school;

c) Even though under-diagnosis may be, and can be, identified as a false-reassurance and potential risk and, although public health messaging may emphasise this risk to the public, all the same under-diagnosis is an abstract concept, not an empirically experienced event, and so, I suggest, can never be fully grasped or ‘felt’ by individuals as having any personally relevant meaning that should influence individual behaviour. This means, in effect, a ‘negative’ result will always erroneously signify, and be believed by the individual to mean, total personal freedom from infection and infectiousness.

A comparison can be made with the risk of over-diagnosis with mass cancer screening, where once diagnosed the possibility of over-diagnosed becomes disavowed, that is it may be ‘known’ but has no affective value, it becomes a ‘unknown known’, and the diagnosed and treated person focuses on cure as a cancer survivor, not as a possible over-diagnosis victim.

d) individual protection versus protection of others: a negative test result, used in order to avoid or prevent self-isolation, permits continued and, if behaviors change, may even increase social mixing, potentially increasing risk to others; on the other hand, for example, wearing a cycle helmet only reduces the dangers of an existing behaviour to the individual, it prevents continuation of the pre-helmet risk to the individual and doesn’t change existing cyclist behaviour in ways that makes it riskier, or safer, for others.

The Pandemic and an Ethics of Responsibility

Hanaamayer (usefully but, ultimately, inadequately) draws upon Weber’s (transcendental) ethics of responsibility to challenge EBM (Evidence Based medicine) principled conviction (rules-based) to determine good medical practice in terms of a supreme good that ‘maintains life’ on the basis of primarily empirical data and mortality outcomes. The ethics of responsibility places responsibility on individual clinicians to recognise that putative patients may not place the same value on mortality as the EBM guidance. For example, the evidence may suggest screening is a good thing because it reduces mortality, or that for example after a screen-diagnosed cancer that surgery is ‘evidence-based’ (on mortality grounds) and so desirable, if not demanded, but bearing the chance of overdiagnosis in mind and the thought of life after mastectomy might be grounds for an individual to decide against surgery.

As far as programmes of mass screening goes the very sending out of invitations and ‘offers’ to screen for life threatenting conditions or risk, already makes for a loaded invitation, invoking inevitable fear and a sense of moral duty to accept the invitation.

At the same time, in our contemporary capitalist cultures the ideal of maximising ‘life’ is endemic and normative, and part of our consumer culture, and so the offer of a test contains the promise of ‘more’, of everything, of happiness, life, health, meaning to life, and so on.  It is in this sense seductive.

At a public health level, interventions are applied en-masse. The public health programmes, such as mass diagnostic testing demand an unconditional application, that is, the application is not conditional of the personal characteristics of any one individual beyond the population criteria for inclusion (for example age and gender). A question then arises, in the light of the first principle outlined in the previous blog that values maximizing individual autonomy over the body, when this principle is considered alongside a political welfarist societal principle: to try to maximise the potential for health of the most vulnerable and at risk in society – whether for reasons, for example, of age, co-morbidity, or poverty.

There are two scenarios we can consider:

First, an intervention may be primarily for personal individual potential benefit, even though it might carry a risk of personal harm (direct and empirical, such as the effects of treatments, for example, a mastectomy on self-image, or virtual and abstract such as overdiagnosis), and may well create false hopes for individuals and financial and efficiency opportunity costs for healthcare services. The individual’s consumption of, and participation in, the intervention does not have any added welfarist type value for others in society, and is only, in a social welfare context, selfish. [Unless, that is, one theorists that one person’s participation encourages others to participate as well, but even in this case it would be arguable whether this would of harm or beneficial for others in society at large.]

Second, a public healthcare intervention, such as a lockdown restricting social mixing to reduce viral transmission in a pandemic, is applied collectively in order to provide relatively greater benefit for those at higher risk.  It is applied en-masse, affects all members of society, and for many at relatively low risk from the virus the intervention requires: a) personal sacrifice of autonomy; as well as b) sacrifice due to the direct harms of lockdown  (for example, loss of income and social isolation, and emotional stresses).

In this second scenario, what is required is a collective welfarist valuation of the lives of those most at risk so that the majority are prepared to make individual sacrifices, even though the ultimate scale of benefit to those at risk is uncertain and the ultimate scale of harms to all are also uncertain and immeasureable.  In effect the majority are being asked (or even commanded by diktat) to risk everything, even their lives ultimately, justified by the value they are asked to place on the lives of the weakest.

Lockdown sceptics

Sceptical voices argue that the risk from the virus are over-stated and that lockdowns cause more harm than good and are an unjustifiable and anti-democratic infringement of personal liberties. 

Some argue that most older people are willing to sacrifice their lives so that younger people may have more freedoms, and that most older people are more harmed and upset by lockdowns than younger people and, in addition, would wish to be allowed their own ‘unlimited’ freedoms, of movement and social mixing, rather than be restricted by lockdowns.  No doubt some of these views are held by some older people.

What is at stake here is political and ideological: a) whether individual practices that are felt as representing freedoms or individual liberty, are actually practices that are in effect self-exploiting and oppressive; b) whether capitalist culture incites a blinkered selfish approach to what are illusory freedoms, and incites an objectfication of the stranger-other, severing social bonds; and d) whether society as such becomes unimaginable and the concept of social-welfarism anathema.

Three issues need to be borne in mind: first, the pandemic, from a welfarist societal perspective is increasingly likely to require authoritarianism as trust in the honesty and competence in central government has been eroded over the last 12 months, and yet, second, authoritarianism incites xenophobia, and finally, third, the current greatest threat of authoritarian totalitarianism and its genocidal consequences, in the West, comes from ultra-libertarianism fuelled by capitalism and supremacist nationalism.

The Moral argument in favour of Lockdowns

Medical Talking Heads on UK LBC radio this  morning, 19/01/2021,  rightly note the harms of lockdown measures, but wrongly demand more evidence of lockdown net benefit – this is necessarily a ‘will-o-the-wisp’. 

In the face of Covid excess and, inevitable uncertainty about harms/benefits, we still know the most vulnerable (oppressed) will be disproportionately harmed by Covid excesses. Lockdown harms to the most oppressed can be mitigated with state financial support. So in the face of exponential growth precautionary early action plus support is the most moral course. Waiting for evidence of net benefit of lockdown is only sacrificing the oppressed in the name of wishful/oppressive thinking.

I draw on Walter Wink’s arguments against the idea of a ‘just’ war claiming what is required isn’t proof of the justification of action (war), so much as proof as to why inaction (not going to war) is worse. On this basis, I would argue that, morally, it can be argued, perhaps against Wink, that not locking down to resist viral transmission is worse than locking down and therefore locking down is a ‘just’ war – a war on the Covid-19 pandemic as well as on the political forces failing to support the vulnerable financially.

In the absence of proof of the ultimate effects of lockdowns we only have political, moral and ideological arguments. Consider the question: Is not locking down (more or less limitng individual freedoms) worse than locking down (not an all-or-nothing thing, but nonetheless, always involving restrictions on individual freedoms)?

We can consider a moral basis that sees a greater good in compelling individual sacrifice by the collective masses in order to protect disproportionately vulnerable minorities from an existential threat (be it political persecution or a virus) as opposed to allowing the minority to perish through a lack of collective sacrifice and neglect.  This would imply that inaction – not locking down – is morally worse than locking down. 

What does this moral basis depend upon, what is at stake?  What is at stake is the valuation of the lives, futures and hopes of the minorities. The lives of minorities will be neglected if the majority do not value, as much as their own, the lives of those minorities, so that the majority are passive, or promote inaction, in the face of the neglect and suffering of the minorities.  For a society to not value the lives of stranger-others, as much as its own ‘in-group’ lives is to lose touch with our common humanity, capacity to care with love for the other. Voegelin in ‘Hitler and Germans’ refers to this as a de-divinisation, or loss of presence to God. In more secular terms we could says that current libertarian individualism incited by nationalism and capitalism incites an objectifcation of both the self and the other that makes unconscious, or disavows the value of the lives of others.

What are the consequences of inaction? It would be a dehumanising moral failure, according to the above argument, that opens the way to a libertarian form of totalitarianism, or fascism, that ultimately, as described by Arendt, referring to Germany’s National Socialism of the 1930s, commands: “Thou shallt kill”

The anti-lockdown brigade and totalitarian threats

In the UK the anti-lockdown brigade (eg Hitchens of the Daily Mail) rightly see in authoritarian Lockdown measures the potential for totalitarianism and its xenophobic consequences. They point to China as an example, and as a regime to be reviled. What, I think, they fail to see, or admit, is the even more severe totalitarian potential in the kind of ultra-libertarian individualism they advocate that: a) is causing very significant excess deaths, and rising, from Covid; b) creates a mass psyche that believes it is ‘free’ whilst it is destroying itself; and c) sustains the fantasy of a caring government whose power and entitlement thrives on the cultivation of envy, and on social division. In this moment it is this more severe totalitarian threat, of apparently caring libertarianism, that is exacerbating the Covid crisis. A moral response is to value the lives of those that could be saved by Lockdown Plus, where the Plus refers to financial support (UBI) for those affected to minimize the collateral harms of Lockdown