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Kordela suggests, in ‘Being, Time, Bíos’, that the biopolitical battle between a conscious illusion of immortality and more or less successsfuly ‘repressed’ unconscious certainty of mortality, is a capitalist phenomenon, where God, as the unconscious, has become immanent to our psychic structures, structured by the University Discourse of Lacan. So I was puzzled to read this paper from 1941 by an American psychoanalyst, Hallowell:

‘The social function of anxiety in primitive society’ – American Sociological Review vol 6 No 6 Dec 1941 pp 869-881  

… which seems to suggest that these presumably pre-secular Indians, the Salteaux tribe in Canada,  also have, or had anyway, a psyche structured by the University Discourse, and an ideological fantasy suggesting a God that is transcendent in immanence. But, according to Kordela,  this shouldn’t be the case for non-capitalist pre secular tribes. I have tried to analyse this in terms of describing what ‘appears’ to be an ideological fantasy, instead, as a form of incest taboo, consistent with an absolutely transcendent sovereign God, but in which Foucault’s biopower (self-subjective objectivisation and self-investment through sin/confession) also seems to be functioning. 

This is a very different tribe to the ones described by Marcel Mauss in his 1950 essays on ‘The physical effect of the individual of the idea of death suggested by the collectivity’ – in which he relates Dr Golidie’s diagnosis of ‘rapid fatal melancholia’ in the Maori, for whom 

‘ … death by magic is often conceived … possible only as the result of a previous sin … true pangs of conscience that lead to the states of final depression.’

Goldie suggests they ‘ … will themselves to death’.  This seems to contrast with the Salteaux.  The Salteaux Indians described by Hallowell in 1941, prayed to their God(s)? for life itself, but had a ‘traditional belief’ that if they suffered an illness that felt existential threatening (mortal) then this was due to sin, theirs, or if a child was ill the parents sin, and that more or less public confession of the sin would provide a God given redemptive cure. 
The Indians still die; at an individual level; but the world goes on; and they seem to pray as if for postponement of the end, and for  a  merciful God that may grant this wish, for a while: but if we assume this God is still an absolute divinity, then this suggests the Indians theodicy is not Neoplatonic and there is no demiurge; (the part of divinity that created the imperfect world that must be destroyed if we are to be redeemed)  then the world is a single and merciful God’s creation, endless, there is no judgement day, in which case, each individual is a Perfect Gods creation – immortal until stained with sin that, for the Indians,  is the ‘fault’ of the individual and brings on premature mortality. 

Now this is the ‘problem’ it appears (and I think this may be a deceptive appearance) that for some pre-secular peoples, like the Salteaux,  sin-confession makes an impossibility of certainty about mortality – as in capitalism; in capitalism Kordela suggests the fault lies in praying for access to the in-itself; (perhaps then, I suggest, also praying for what would ‘fill in’ the ‘lapse in being’ (Zupancic),  created through sexuation and knowledge of origin, resulting in the explosive proliferation in e.g. porn, tattoos, medical investigations and excess). For capitalism this drive for the in-itself, for the mark of mortality (the diagnostic and prognostic risk, the tattoo), is forbidden to be based on any single certain gaze, since the calculations of surplus value achievable through darstellung demands the illusion of immortality; and in a ‘liberal’ non-coercive way, makes this ‘certainty’ ‘impossible’. But because ‘no gaze’ would be traumatically non-sensical, the biopolitical mechanism of capitalism relies on what Kordela calls radical uncertainty and the continual sliding of gazes, rather than the ethical eternal dimension of (infinite, but which on the ontic level appears as ‘no gaze’). 

However, to return to the Salteaux, their unconscious, as pre-secular and pre-capitalism, should be absolutely transcendental – as in God’s ‘will be done’, which suggests that the question of knowledge only arises through the taboo that makes sense of the lapse in being, e.g. the incest taboo; and for the Indians the taboo lies in the sin for which they take responsibility and for which illness is punishing them, perhaps through God’s will. (and their knowledge does not rely on a secondary ideological fantasy the repressed an immanent unconscious). For the Salteaux, being responsible for, or the reference for, your own mortality, is a form of incestuous self-referentiality, and so must be taboo, since the self as the reference for truth is not enough to make sense of the lapse in being, the vacuum of sense. The Indian still only has one specific gaze; that of the transcendental deity, the sovereign with the power to take away life. The Indian has developed a form of self-discipline equivalent to the exercise of Foucault’s biopower; this is a subjectivisation under the all seeing eye, not of earthly dispositifis, but of their sovereign God. The Indian is certain that God’s will be done, and they pray to God for maximum life, which they value highly. For the capitalist man – it is different – in a few ways – he is certain of his mortality – he sees or knows of people dying all the time; he has a desire for knowledge that will make good his lapse in being, his sexuation, his origins, especially in the face of existential threats; and capitalism’s social relations depend upon pure differentiality, exchange-values, and creation of surplus-value, which, to appease apparent freedom of choice for the subject, makes the certainty of mortality not just forbidden but impossible; instead the illusion of immortality is sustained through repetitive prophylactic acts to prevent one specific gaze (such as a mortal illness like a fatal heart attack), after another – which Kordela refers to as the sliding of gazes (since the ethical eternal infinity of gazes, would feel like no gaze on the ontic level, which would be unbearable) which hystericises the subject/patient who seeks satisfaction from each gaze but always fails. In contrast to the Indian, the capitalist subject of medicine, is always already suffering a mortal existential and traumatic threat, and constantly repetitively seeks the specific gaze, cause of ‘premature mortality’, in order to prevent its effects. This works across health, lifestyle, and materially. A limitless plethora of gazes, is furnished by scientific discoveries of bottomless reservoirs of indicators of potential threats to guard against such as reconstituted genomic markers indicating future risk of biological disease. For capitalism this serves the function of maintaining the capitalist industries with new means of production and new products, whilst intensifying the productivity of a labour work force, eager to work for free, to work compulsively, and to work repetitively, and endlessly, across an expanding array of biopolitics factory sites. This proletariat is under the illusion of immortality, of working as if for the self, sometimes harking back resistively to the mark of vertretung the organic link for the subject to his certain mortality – and perhaps this is sometimes reflected in self harming behaviours, tattooing, maybe the personalised number plate, maybe the selfie, maybe part of the continued consumption of substances of harm for dependent people, maybe even suicide à la Madame Bovarie. There may be a spiritual gap here, the lack of a transcendental sovereignty, to give life a sense of certainty of meaning, that leads us to moral dissolution, pointless existential angst, and self destruction. 

The pre-secular Indian is in a mode of exchange that is just, juridical, where exchange is equivalent – a confession for life; there is no surplus here, God ordains when the confession is equivalent to the sin, and returns life or not. The incest taboo for the Indian includes the self referentiality of personal mortality due to personal sin. 

Is it possible to write a genealogy of medicine to the modern day? A genealogy of post-structuralism, of the floating signifiers of pure difference, (the test result, the QALY), that make possible the diachronic sequences of symbolic exchange through dia-gnosis or pro-gnosis (?knowing what lies ahead), of Broussais’s ‘normality’ – Canguilhem’s aspirational impossibility, of Kordela’s secular shift of capitalism, and the, ongoing, battle between a specific gaze of certain mortality – and the infinite choice of gazes in a sliding hystericised financialised, compulsively utilitarian market place, and its promissory commodities, and radical uncertainty.  
Medicine functions in a dynamic and non-uniform culture – with resistance, multiple, repetitive, individualised and sometimes social, against corporeal subjectivisation, the strange pairing of capitalist-self entrepreneurial-consumer; labouring as wage labourer, forced to labour because of the original sin of mortal abnormality lurking within to be eradicated at all costs, to create a commodity, of congealed labour, congealed fear, purely to make surplus fear, still in just as much debt as before, to labour again through the consumption of the next dia- or pro- gnosis, and so on, endlessly. This is a labour of alienation, through the self-processing by medical technology, where part of the product to be sold on, not owned by the subject, is the compliance with the prophylactic cure, an element of exchange that creates surplus economic value for a range of merchants, and producers, universities, industry, politics, and medical practice. The subject, of this capitalist power, can resist, turn away, but is always called back, the siren call of the loan sharks, “you’re in trouble, we feel sorry for you, but we can help, just come into our little shop for a chat, … ” – where the loan is the promise of cure, the debt your mortality. The consumer of this loan disappears as a subject in a flux of pure differences exchanged time and time again, under the illusion of immortality. 
It might be possible to describe this as a psychoanalytical Lacanian-Marxist framework for understanding how neoliberalism necessitates population level medical overdiagnosis, and over/under treatment by using innovative prophylactic and predictive genomic technologies to peel back layers of corporeal raw materials and subjects in radical uncertainty and existential fear, torn between embracing an inevitable/certain mortality, by making their mark on their mortal bodies, and the illusion of immortality demanded by darstellung’s promise of surplus (that doesn’t so much forbid mortality as deem it impossible), by accumulating wealth, monuments to the future, predictive test results and their prophylactic consequences. The neocon medical empire demands Darstellung, demands action ‘now’ on an expanding battlefront against the inevitable. Discourses of mortality seem to be non existent until the terminal state has manifested itself in a variety of ways. Only then is mortality discussed as a possibility, in another, sometimes illusory optimistic world, of Ehrenreich’s ‘pink kitsch’. 

The biopolitical battlefield is between the  ‘vertretung’ of equivalence between the perceived promise (wages) to alleviate risk and the resultant debt (the self ownership that is Foucaults subjectivisation and self entrepreneuriality) which puts the subject (potential labour power) into active labour, and the fictitious ‘darstellung’ where what is exchanged is surplus fear or apprehension which has only an arbitrary relation with the congealed affective labour in the product – the compliant and ‘more afraid’ patient. Affective labour is working on the risk score in the PGT – predictive genetic test – machine, producing self valorising apprehension that maintains a permanently increasing indentured slavery and indebtitude that guarantees endless expansion of productivity of the body through eg the re-constitutions of the genome into more machines. The person exchanges his potential labour power as ‘vertretung’ outside of the circulation of apprehension where labour is converted into congealed labour in the product which generates surplus value as exchange value, as ‘darstellung’. 
Apprehension, in a sense, buys the promise and ultimately is exchanged for more apprehension. Apprehension is the universal currency of the patient. 

Here we have a classification from Marx: “Freedom, Equality, Property and Bentham” Marx cited by Dolan, drawing on Kierkegaard’s use of ‘officers, maids and chimneysweeps’. Where Freud referred to psychoanalysts as chimney sweeps. (In ‘Sex and Nothing’ ). 

The beauty of this is its ironic exposure of the impossibility of eg science to ever be capable of totalising nature and humanity in classification systems – what is universal is the contingent – but what if …. what? Precisely – we don’t know what, but there is definitely a ‘what if … ?’
So , for fun, we could have a classification: all we need is:  

‘illness, health, risk, vaccine, peanut butter’

… where peanut butter is the contingent, both life-giving, desirable and ubiquitous and life threatening, feared and forbidden. 

The Transmutation of Debased Flesh – Medicine’s Elixirs of Eternal Life .
Medicine’s glorified alchemists and the repression of overdiagnosis. 
On physical and mystical matters and the Philosopher’s stone: the practical and the esoteric, the secret repressed symbolism and its magic power invested in the gift. The secret of immortal life. 
Jung’s vol 12 ‘psychology and alchemy’ – covers similar territory – the projection of the unconscious, through symbols, onto the material world in order to take the place of God the redeemer, man has become his own redeemer of himself, in an alchemy that attempts to find the immortal spiritual core of his nature. Just to note the similarities. 
In ‘alchemy and psychology’ by Jung: 
QUOTE:

“From this point of view, alchemy seems like a continuation of Christian mysticism carried on in the subterranean darkness of the unconscious…. But this unconscious continuation never reached the surface, where the conscious mind could have dealt with it. All that appeared in consciousness were the symbolic symptoms of the unconscious process. Had the alchemist succeeded in forming any concrete idea of his unconscious contents, he would have been obliged to recognize that he had taken the place of Christ – or, to be more exact, that he, regarded not as ego but as self, had taken over the work of redeeming not man but God. He would then have had to recognize not only himself as the equivalent of Christ, but Christ as a symbol of the self. This tremendous conclusion failed to dawn on the medieval mind.” (Part 3, Chapter 5.1).
It is almost as if the mediaeval alchemists were the first capitalists making transcendent Surplus immanent through their alchemical projection of their unconscious onto matter. Where spiritual re-birth through alchemy generates the surplus-value. “Man had taken over the work of … redeeming God.”
In Kordela: man in a sense projects his original sin onto the search for immortality – for his own elusive philosopher’s stone; through a symbolism of mysterious and mystical genomics that can see into our future and reveal the elixir of immortal if not eternal life. 

The QALY and capitalism a Lacanian/Marxian perspective 
The Quality Adjusted Life Year is used as a measure of healthcare effectiveness – used to compare lengths of time in different ‘health states’ – it is produced through citizen or patient opinion groups so is always in the line of the imaginary and might be better called Desirability Adjusted Life Years. It is ‘ostensibly’ to enable ‘decision makers’ to choose between different medical interventions when resources are scarce. Capitalism transforms the value of a health state by increasing its desirability by promising the fantasy that what is desirable is actually achievable – one step on the route to a death infinitely postponed. This is how capitalism turns money into more money, or a desirable health state into a more desirable health state, or signifies your current health state (whatever that is or how formulated) as undesirable, inadequate. This is consistent with Broussais’ ‘normal’ so matches the (imaginary) diachronic narrative of medical progress as progressive. The QALY is not simply a comparative ‘equivilator’ for health – a currency – it is the means by which the infinitely deep reservoir of potential pathology in the body is envisioned and mobilised by capital. 

PS : Fantasy
The QALY ‘appears’ on the surface, to be  ‘liberal’ -(‘as if’ promoting justice and egalitarian ideals) but instead, it normalises a standard life that makes ‘real’ life into a pathology. The actual desire isn’t important (in diachronic time this might be … Say  The diagnostic  test itself or the treatment) what matters is the fantasy behind, immortality. It, the QALY, hides a positivism, that is in a dialectic co-dependent relation with capital. One is a condition of possibility for the latter. 

With thanks to, and  inspired by, a seminar on ‘Metamorphoses of the Brain’ by Jan de Vos, and on ‘Religion and Psychoanalysis in India’ by Sabah Siddiqui hosted by Ian Parker and Erica Burman of the Manchester Discourse Unit on the 16th May 2016. This is about the production of ‘faith’ as a surplus value that, after Marx,  requires both circulation, and not-in circulation, time

So, the inspirations were to do with ‘the brain’ as ‘thinking matter’ interacting with ‘test results’ as manifestations of spirit-ghost-signifiers in the form of ‘extended matter’ (in diachronic production-linear time), transforming subjectivities in the shrine of the medical market place (in synchronic circulation time) to create a trance-like state of enhanced faith and a transformed subjectivity.

This is a Marxist economic analysis of the patient and the pro-diagnostic test. For those not familiar, a pro-diagnostic test is one like Oncotype DX, a genetic signature that ‘tells’ you how likely it is that your breast cancer will recur so that you can make better decisions about whether to have further chemotherapy. In general terms this analysis applies to all medical and predictive and screening tests.

This analysis describes a sequence of Medical transformations of patient subjectivities: from ‘potential patient’ to ‘patient’ to ‘compliant patient’ to ‘treated patient’. You might see parallels with Foucault’s process of subjectification or subjectivisation.

I did wonder, in my last blog, if the ‘number’ of the ‘risk’ provided by pro-diagnostic tests: (x% chance of event ‘y’ in ‘z’ time) was a form of labour-power (see previous blog[1]) . I now see it more as a combined ‘number-patient’ labour-power, where the number is a material ‘given’, a written or spoken object with use-value as a kind of raw material that interacts with the thinking matter of the ‘patient’ to create anxious-hope, an enhanced need for reassurance and an enhanced faith that the result will mean ‘longer’ healthy life, and, therefore, enhanced compliance. So, here, the ‘number-patient’ acts as labour and works to produce something of use-value to the medical industry: the labour-power of ‘a compliant patient-customer’ willing to pay to be provided with and subject to, with the help of the physician-merchant middle man, medical ‘treatment’.

Lets take the person whose early breast cancer has been treated. The putative asymptomatic customer/patient is ‘offered’ the opportunity to enhance their life chances. Tempting that must be. In a Faustian pact the patient sells his soul and signs his name in blood – hands over his genome to the devil. He/she has entered a world of perpetual indentured debt – life from now on will absolutely depend upon perpetual and repetitive self-objectivisation, handing over of bodily knowledges, and consumption of medical technology.

Here the patient willingly offers his/her labour-power and provides the raw material for the product (‘risk’), that he/she will use, later, to labour on, to transform him/herself into a profitable customer. The patient pays for this product (the test result ‘risk’), that industry ‘makes’ in the lab, (with the lab’s labour-power generating the first phase of surplus economic value for industry).

When the patient receives the result, he/she subsequently labours on the ‘risk’ and this completes the production process and generates the commodity of use-value to industry: ‘the compliant patient’, willing to pay for him/herself to be provided with, and subject to, the treatment ‘ordered’ by the ‘risk’ in the test result. The patient objectifies him/herself as a commodity object, and is then subjugated by industry and turned into a ‘treated patient’ subjectivity.

Put slightly differently, the test result is the product of labour carried out on the genome, already provided by the patient, as bodily raw material. It was at that point that the patient tacitly agreed to receiving a result, (and to ‘labour’ on the result), and to comply with its outcome. This is the meeting of the capitalist with the labourer free to sell his labour in the market place – the slight extension here is that the labourer first provides some bodily ‘knowledge’ that will be transformed into ‘risk’, ‘risk’ that will then be given back to the ‘patient’, to labour on, and to transform him/herself into an anxiously-hopeful ‘compliant patient’ and customer/consumer, able to generate more surplus economic value for industry by becoming a ‘treated patient’.

The fatal flaw in all this is the mythology and superstitious belief in the power of the test. The scenario above is the acting out of a kind of worship in the temple of the consultation, using the body in a sacrifice that has been sanctioned already by the quasi-religious authorities. The other interesting question therefore is how the religious authorities decide which sacrifices to authorize. For our purposes this is asking the National institute for Clinical Excellence how it decides to authorize tests like Oncotype-DX to be an official ‘spirit’. It has already been clearly shown that tests like Oncotype DX are under-regulated, over–valued in terms of their clinical utility, over valued economically, and unaffordable for publicly funded healthcare systems.

[1] https://myownprivatemedicine.com

A ‘Thank You’ to Ian Parker! for encouraging and listening. 

When is a number not a number? Why can number exert force as a cultural power? 

The medical industry produces tools for man to use in his work, his productive labour. The tools might be predictive diagnostic tests. This tool is ‘used’ by what we call ‘a patient’ to make a test result, ie a commodity with use-value. The ‘patient’ also consumes this commodity and in the process increases its value by producing an increased faith in his own immortality, or what we could call a growth in the significance of consumption for longer life. The test result is a numerical signifier that signifies the promise of immmortality as long as you keep buying the ‘tools’ from industry, (the tests), using them (having the test), consuming the fruits of your labour (complying with the result), consuming your own body- repetitively, endlessly. 

Here goes; this relies on some Sheperdson on Lacan, some Marx in Capital, some Kordela on biopolitics and some Ian Parker in tutorial! Thank you Ian. 

The ‘Limit of the Numerical’ does not exist, because it is a signifier, or a specific gaze that to function must entail the presupposition of an infinity of gazes, or signifiers. It has infinite meaning potential.

The signifier signifies the subject for another signifier and the subject, as such, only can be said to exist in a wrinkle of time in between the enunciating act and the retroactive constitution of subjectivity that is torn away the very moment it appears.

So. With number we have a signifier, that like all other signifier’s makes the subject both appear and disappear at the same time.  

The number functions, like ‘capital’ to expand its own value as surplus semantic value. But like capital it requires a commodity that increases in use-value as it is consumed. The commodity in mystical terms that achieves this is the labour power in the numerical risk prediction. The x% chance of event ‘y’ in ‘z’ time.

So here we have: industry provides the ‘tool’ which is the pro-diagnostic test, this produces the number ‘x’ as a percentage risk. This number works, as it is consumed, to produce use-value in terms of surplus semantic value – i.e. fosters the impact of the number as a master signifier of the belief in neoliberalised medicine’s promise of immortality. This surplus semantic value is itself a use-value for industry (and perhaps others), that is also consumed and creates more surplus semantic value, like capital or surplus economic value. It functions to ultimately command compliance. A patient – exposed to such a signifier – must make choices, coercive but not absolutely positive, to comply or not comply. There is no subject just a subject’s Total Compliance with the Law of the Number – a castrated masculine subjectivity, or,  a subject’s ‘not-all’ compliance – a feminine response. But feminine as in ‘if’ the patient is ‘not-all compliant’ then the patient becomes ‘all-compliant’ to some other Master Signifier or Law, not the Law of the Number, but something else we cannot name, identify or be certain of as ‘analysts’, looking from the outside – our imaginary perspective. 

The numerical can be like capital – a self valorising magical signifier that ‘appeals’ to the hard work, thrift and avarice of the capitalist – the all-compliant servant of, and slave to, capitalism. The Limit to the Numerical’ is the taboo for the totem of the risk-addicted capitalist tribe. 

Firstly a little orientation to my polemic. I’m working on the way decisions are made to invest in new medical technologies for the NHS. There is now good ‘evidence’ from health economists that the effectiveness of the health service is suffering and demand on services increasing because of the emphasis on innovation, profit and prevention.

Basically the focus on investing in innovative molecular biotechnology such as genetic testing for future risks of disease is draining resources out of not-for-profit health services like the NHS. This is in effect sacrificing the effectiveness of the NHS by imposing costs in order to enable industry to make profits. The tax payer is paying for the profits of industry in order to have less effective healthcare. Clearly a scandal. The authors of this are highly ‘respected’ authorities who appear to be meek and humble servants of ‘the people’ but in reality are more like servants of the God Profit!

In the context of an ongoing medical holocaust the biblical quotation sums up the ideological illusion of a capitalist medicine.
The meek is the confident, of sober judgement of his abilities, assertive and yet a servant of God – promoting the aspiration of a heaven on earth. Crucially, to be ‘meek’ is to be the servant of some God, or ideological fantasy. ‘Power under control.’ It describes an aspect of Foucault’s kind of subjectification.

Scientific governmentality is ‘meek’ under neoliberal controls promising a heaven on earth to its flock in a ‘humble manner’.

Scientific innovation is blessed by its God of Surplus Value. Ultimately narcissistic, a false humility – condemning the flock to an illusion based on the promise of surplus life on Earth. Condemning the poor in material wealth to be so much organic waste. Much like the industrial neoliberalism in the USA in the 1970s before the oil shocks, financial crisis and eventually Reagan’s radical deregulation of the molecular biotech industries, amply supported since by further neoliberal politicians such as the Clintons.

This is still a thanatopolitics but does not require sovereignty or sovereignty power but rather a capitalist ideology and its multiple contradictory and over determined systems of control where the really lived experience is based on the imaginary relations between people. (Althusser). And where The Law is not a religious God but is surplus value – where the primal father, ‘Le Non du Père’ demands a taboo: Thou shall NOT ‘Sacrifice PROFIT OR sacrifice Impotence of USE VALUE’ Where impotence refers to the need for capital to make profit in a process that causes healthcare to become impotent. Financial Power for the few through ‘meekness’ becomes material impotence of the health services for the many.

Financial power needs ‘good’ foot-soldiers to meekly and humbly administer this power ‘as servant to Capital’ in the name of preserving life but in fact wasting life itself. This is a psychic structure of anxiety and radical uncertainty, a discourse of the University. Some may see a capitalist discourse or a psychotic discourse in which the truth of the subject of capitalism becomes the object of consumption – of his own Bíos represented by his organic body and its deorganised recombinant genome, suffering a lack of lack – a perverse certainty in a sadomasochistic relation to his subjectivity. In the UK NICE aided by EBM and clinicians provides the humble foot soldiers and the meek leaders in this unholy assault on ‘the other’, the ‘patient’ subaltern – the patient patient waiting for heaven on earth but doomed to disappointment, to neglect.

The taboo is also an internal contradiction waiting to crash – every financial profit made involves a loss of the use-value of public healthcare – the masses are suffering a preventive medical carpet bombing of Vietnam like proportions, and billions of paupers yet to kill. This medical holocaust will go on for a long time yet.

Apparent meekness in a foot soldier may mask a narcissistic self regard whilst being praised as ‘good leadership’ – this meekness is always a servant to some God. Ask what God is this apparent meekness serving? Cui Bono?

There shall be no limits to the costs imposed on the health service to forgo health gains. NO ‘Incremental Cost and Effectiveness Sacrifice Threshold’ no InCEST.