"My OwnPrivateMedicine" by Owen Dempsey

Category: Uncategorized

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

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

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

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

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

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

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

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

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

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

  • The ‘Abstinence’ rhetoric and the Pathological Heroin-Thieves

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

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

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

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

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

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

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

  • Lacan’s Logic Of Perversion and the Medical Fantasy

     

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

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

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

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

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

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

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

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

  • Fodder for Medical Perverts – Zizekian?

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

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

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

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

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

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

  • Misrecognition is Medicine’s Truth

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

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

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

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

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

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

  • The Sublime Object of Medicine

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

    “All Power is through the illusion of knowledge”

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

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

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