Mrs Thatcher the Prime Minister of the UK Government PLC in the 1980s, and one of the architects (with Reagan of the USA) of neoliberalism, referred to the miners’ Union under Scargill’s leadership as ‘The Enemy Within’. Perhaps the sadistic destruction of the mining industry by a masochistic corporation, British Coal (under the American McGregor) is a metaphor, and a forerunner,  for the autoerotic self destruction of the individual today within the discourse of the market. British Coal had to destroy itself by consuming that which enabled it to exist. Perhaps Capitalism itself will one day also self destruct by the consumption of humanity as we know it, the humanity that enables capitalism to exist.

Below I am going to link relationships between structures of discourse consisting of a ‘truth’, that supports the activities of an ‘agent’, that puts to work a tool to produce a commodity.

And now the jump to medicine. The expert physician has the means of production, this is ‘all knowledge’ (S2)- arcane, mathematical and beyond the ken of mere mortals – this is the discourse of the University. ‘All knowing’ expert (S2), puts to work a gadget, the ‘medical-test-dia-gnosis’ (tool of the hetero-genesis that is dia-gnosis), known as ‘a’ in Lacan’s typology; the test heterogeneticises and produces the subject, like Foucault’s madman, always already ‘marked’ by the process of hetero-genesis (that is dia-gnosis) as the ‘patient’, $ in the typology. The truth that warrants the experts knowledge is S1 – the logic of mathematics, and the mechanistic autonomous rationality of probabilistic reasoning and the Cartesian Mind.

Evidence Based Medicine is stuck on this Cogito of Descartes and this discourse of the University, and remains alienated from its product the patient; and reinforces the loss of the Master experienced by the subject of the discourse of the Market, of capitalism.

The dynamism between the structure of the University for both the medical expert and the ‘patient’ and the structure of the discourse of the market is the transition between states of neurotic and perverse psychic structures from anxiety about the indeterminism of the desire of the other (little ‘o’ refers to a concrete other in front of me) awareness of the lack of the Other (capital ‘O’ refers to an imaginary fantasised Big Other, witness that sees me as I am) being personified by the lack of the concrete other.  The patient’s desire to be desired by the expert, seeing the expert as lacking and a void that the patient seeks to fill by being desired – the relationship, like the neurotic sexual relationship that must always reach an impasse and fail. The market of capitalism entails the disavowal of the Other, though the Other is still functioning as a disavowed witness in the unconscious.  The autoerotic paradox is that the sadist refuses to be the incarnate flesh object, for the patient now has to be his own subject-agent, sadistically forcing himself to desire  and attempt to achieve satisfaction by forcing himself to be flesh, the object of his (as subject’s) desire. And then, when flesh is offered up by his masochistic objectivity satisfaction must be refused to torture the masochist objectivity within.

As the flesh is sacrificed in hope of satisfaction it is simultaneously refused as inadequate for satisfaction. The masochists hoped for total humiliation as the object of the sadist-within’s satisfaction is dashed, and the sadist’s hope to see the masochist humiliated and objectified is also dashed and the whole process must be repeated ad infinitum  to attempt to achieve satisfaction, again and again. This is the impossible libidinal circle the patient and the medical expert both play independently of each other within the structure of the discourse of the market, roles they can play using the tools and structures set up by the discourse of the university. What is the role of the discourse of the university here? Presumably it does continue to counter to some extent the discourse of the market as it does continue to be evident, evidence of neurotic anxiety. So can structure of neurosis and perversion exist within the discourse of the market? The market induces an ontological solipsism and is the end result of a process ontology theorised by Marx’s historical materialism. The neo-human necessitates the death of man, is defined by tools that enable permanent regeneration of a neo-humanity – perhaps through no longer a Heideggerian becoming?

The body is becoming an embodied commodity: ’tissue’ as materialisation of ‘objet a’ of the structure of discourse of the market as ‘flesh’ – ‘flesh’ being an abstraction for the excess resulting from the anthropological mutation, like an electron changing levels, as subjectivity is de-negated by lack of the Other, and becomes asocial, autoerotic, driven by a need to consume ‘flesh’, a process that finds some consummation in medical dia-gnosis that insists upon ‘flesh’ production for consumption as a necessary product of its framed logic, that subverts itself to ensure more ‘flesh’ is always, limitlessly, available (due to the Real of Normal being impossible and always just beyond the grasp of the test). So ‘flesh’ excites and is the excitement of the lack of Other in the market – the ‘test’ is the act of consummation that produces its materiality – ’tissue’. Flesh becomes Tissue. The fetish Flesh becomes Tissue through the human abstraction that is the form of Tissue Reality which is Pathology. We can only see Tissue as a form of Pathology – embodied and fantasised ‘flesh’ – the lack of Other insists Tissue becomes Flesh to attempt to provide satisfaction though this is never achieved.  The lack of Other Produces the subject’s uncanny perverted creaturelyness of Heidegger, is the subject of precarity of medicine produced by The Medical College and its scientists and its thanato-political,theranostic genomic enterprise and is the subject of perversion that ‘simply follows orders’ the bare subject, ‘homo sacer’. Which leads me on to wonder if genetic engineering is an authentic ‘act’ that will change our co-ordinates, by creating different life forms: a neo-humanity, will reframe the normal-pathology opposition into a non-life:life opposition, a new frame where biological non-life becomes the new demanded impossible that will materialise as a fantasy for ‘species-suicide’ – question might be: how will this manifest itself? Or is it already manifesting itself through the obvious destruction of us in our world. How will the expert/patient perverted subject-of-precarity use/be-used by this novel technologically demanded logic of enframement: non-life/life?

There are limits to thinking of genetic risk as ‘individual’ as opposed to population, especially given the genomic profiling with MammaPrint and BCtech🎧 and the obesity fingerprint being administered ‘free’ to the Obese on the NHS in Essex. What might aid understanding is a psycho-biopolitics of Neogenic Theranostics. Taking genetic engineering to the next level. Beyond Foucault? But how? There is not just a ‘political strategy to make life’ – “Be Alive!” Is a motif that provides one source of flesh and an angle for threats bribery and torture; but just one source; and the tool is ‘the test’ the ‘test-dia-gnostic’ (all the tools are ‘tests’ that demand and monitor and then act upon difference: hetero-genesis; one example of this is the ‘test-medical’ but there are also test-racial, test-gender, test-economic, test-benefit and there is a tactical polyvalency amongst these. In addition to a political strategy the ‘Be Alive!’ Motif is partly rocket-boosted by capital’s engendered lack of the Other of the discourse of the market. Which makes what was the desire to be loved by the other into an asocial and autoerotic fetishistic crazed cannabilistic orgy of neogenesis in which species-suicide is the dominant trope. The medical expertise is aiding and abetting this process by hiding behind a gated Cartesian cogito with its logic of mathematics and probability. This legitimises ‘expertise’, and securitizes/produces/responsibilises the (now creaturely, unbarred) subject ripe for the market.

“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.

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.

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)

http://www.centreforsocialjustice.org.uk/UserStorage/pdf/Pdf%20reports/addict.pdf

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.

http://www.bbc.co.uk/news/world-australia-32274107</

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.

PERVERSE TRANSGRESSORS

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.

See:
http://www.birminghammail.co.uk/news/health/ian-paterson-ordered-take-psychiatric-9057038

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

https://myownprivatemedicine.com/2015/04/20/the-sadomasochism-of-capitalism-and-the-addicted-subject-of-precarity/

2. Lacan and Debt, by Andrea Mura

https://docs.google.com/file/d/0B6u0lXR-VvCVeU5KTmlVMjRQZlg0STFTaHZScXVBVTN2SERJ/edit?usp=docslist_api



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

(Mass Psychology of Fascism 1993 Wilhelm Reich)

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

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

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

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.