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.

 

The InCEST Taboo for healthcare is how the use of a measure that threatens the market’s power to make surplus profits is essentially forbidden though much measured and regulated; it is the ‘Incremental Cost and Effectiveness Sacrifice Threshold‘ taboo – better known to health economists, and masquerading as, the ‘incremental cost effectiveness ratio threshold’.

This is a brief post that relates what is called the primitive ‘incest’ taboo to the way the USA has made it illegal to use cost-effectiveness data when deciding whether to purchase expense innovative medical technologies for the publicly funded health care services (Medicare or Medicaid in USA, and NHS in UK). The point here being to illustrate that decisions about healthcare funding are a) controlled by the market, b) rely on capitalism’s (need for) fantasies about the limitlessness potential for future surplus profits and immortality. The incest taboo, described by Levi Strauss the anthropologist, takes many forms but seems to have been universal among primitive tribes.  The philosopher Kordela in her book, ‘Being, Time, Bios‘ relates the incest taboo to man’s need for what she calls ‘surplus’ which in primitive times may have been in the form of spirits or later a monotheism. Today, in our capitalist mode, we have another form of God to worship, surplus as surplus value, or profit;  this fosters the illusion of immortality. In this short post I discuss how this manifests itself in the domination of the healthcare market at the expense of public health.

In the UK we have NICE (the National Institute for Clinical Excellence) which regularly agrees to purchase highly expensive technologies at the expense of of total population health. I find this quite shocking – it took me a while to comprehend that this is even true! What follows is a philosophical comparison between the reasons for our well known and trans-historical incest taboo, and the way the UK/USA are making any threshold for purchasing cost-effective healthcare taboo. As brief background: new interventions have a cost-effectiveness measure and this is compared to existing interventions. If the new intervention costs more per unit of health gain than the existing this is indicated by  the incremental cost effectiveness ratio (ICER). If this care is purchased the money must come out of existing care somewhere else in the health service.  But don’t worry too much about this as its not critical to the discussion.

Going back in history, man cannot make sense of a time without beginning, or an ‘origin’ – as a result,  the primitive incest taboo’s essential function is to ‘legalise’, formally if you like, that which is already a necessary impossibility – that is the impossibiity of being able to ‘make sense’ of being human through a solely self referential mode of being, in the face of the unavoidable non-sense of the problem of ‘origin’. Incest is a self-referential activity, at the very least, in terms of reproducing your own genes.Simply put, if you can only refer to yourself as the source of knowledge you’ll never be able to make sense of it all. So incest becomes taboo, a taboo legitimised by a Law, a Law according to a faith in something transcendental, a God of some kind, something man cannot physically experience but only imagine.  We ‘need’ a reliable guarantor of ‘the truth’. (The question of the origin of man and the taboo is another interesting philosophic detour full of mind bending paradoxes so we can leave that to one side for now – see Kordela if interested)

So, to make sense of the non-sense of origin (infinity, time, mortality) we turn to fantasy. We must have faith in an Other we can refer to instead of being self referential – and the function of the Other is to provide a phantasmatic basis that enable us to make a kind of sense of the problem of ‘origin’. Or, if you like, that enables us to disavow the reality of the non-sense of the problem ‘as if’ life makes sense, really.

The InCEST taboo – (‘Incremental Cost and Effectiveness Sacrifice Threshold‘ taboo) performs the same function for healthcare in capitalism – it prevents the contradiction inherent in the self/referential effects of sacrificing surplus economic value in order to maintain population health OR making surplus economic value whilst sacrificing population health, both of which undermine the sense making effects of the illusion of fantasy of economic growth or immortality respectively. This would result in the loss of the ‘surplus’ of capitalism and would therefore force a self-referentiality crisis. The loss of the capitalist fantasy ‘Other’. This would result in a non-sense that would require an alternative ‘Other’, or a renewal or reinforcement of the taboo to re establish faith in capitalism’s ‘surplus’.

In brief, very expensive high-end technologies such as genetically based molecular diagnostic tests, or cancer treatments, are being funded by the NHS even though they will result in a need for health trusts, already under great fincancial pressures, to disinvest in highly valuable servces such as mental health services, thereby leading to a deterioration in population health.  This is being done, in the name of preserving innovation, and business, or to provide treatment for special cases, with lobbying from special pleaders, e.g. for childhood cancers, withough identifying who is going to have their care withdrawn as a result.  The InCEST taboo ensures this can continue, surplus profits continue, the fantasy of immortality continues, but the healthcare available for the public deteriorates. The InCEST taboo will also become evident if the transatlantic trade and investment partnership between the US and Europe becomes law, when e.g. American business will be able to sue the UK if it fails to ensure that it can make its profits, unimpeded by worries about public health,  and penetrate our NHS markets.  The end of the NHS is nigh.

 

 

This is drawing upon a chapter in  : ‘Being Time, Bíos’ By Kiarina Kordela

entitled : Aristotle’s discourses: chapter 9

She is linking Aristotle’s writings comparing and contrasting ‘household management’ and ‘the creation of profit’ with Marx’s analysis of capital, and in the end through Lacan’s psychoanalytical structure of discourse to the Hegelian-Marxist Master-Slave dialectic.

The could be titled: Health economics, capitalism and the crisis of EBM.

Or: Why every medical student should be taught Marx:

A key idea here is that risk has become calculable and Calculable-Risk e.g. is a potential avoidable future risk incurred if you do not consume a particular  preventive medical intervention. Crucially it has both use and exchange value and acts as a surrogate coinage, or capital for the market.

Another key idea here is that the core of EBM should tackle this: the dependence of a capitalist EBM on the production of excess, surplus risk, surplus value.

‘Risk’ in capitalism functions as capital; it is manufactured not only for its ‘use’ (to produce any goods just sufficient to satisfy life’s necessities) – as in a ‘natural’ way;  but also as an exchange value, where risk functions as capital, ie as an economic value that itself generates more surplus value (surplus profit, here defined as excess or surplus to needs)   with each exchange. Risk does this as a surrogate for coinage by virtue of its status as a semantic value as well.

In other words, the market calculates the price of risk (eg in terms of a cost per QALY) which functions as a coinage of exchange value so that the market accumulates  wealth through selling technology for Calculable-Risk (Cost per QALY) as a surrogate for Profit.

The selling of risk has a ‘use value’ potential , i.e. to reduce risk of future pathology or disease, but each sale generates ‘interest’ in terms of  more value, surplus value over and above its ‘use’ value,  in terms of its (semantic) meaning or value which is in part  to coerce more purchase of more so-called risk-reduction technology. ‘Risk’ as capital can be thought of as the QALY (Quality of Life years) lost if for example you don’t buy/consume this new innovative technology; its opposite ‘Security’ is what you must spend money on in order to ‘enjoy’ the surplus value in the interest gained on existing risk ; this further capital is in its exchange value in the form of increased subjective precarity which now functions as capital for the next medical intervention, promising to add further surplus value, and this process is without limit. Risk is the coinage of exchange, capital, that increases in semantic and economic value through each cycle of exchange because it increases in semantic value through each cycle.  Its use value is to reduce risk (promise a life extension), but its exchange value promises, paradoxically, more risk or precarity  in the sense that life now seems riskier, requires even more security, security you will be prepared to pay more for. Every ratchet up in risk reduction technology ratchets up the desire to reduce risk further, the libidinal fear value of biological precarity, or ever more fearful and imminent mortality, the fear of death. Every ratchet up in fear technology thereby increases its economic value, its ability to garner surplus profit.

The NHS works as slave for the Master, the molecular diagnostics risk market; and personalized preventive intervention markets (Statins, Vaccines etc). The market takes pure economic profit at the expense of the NHS if the NHS replaces interventions with cost neutral interventions, so the NHS just works to produce more QALY (Quality of Life years) for the budget, creating surplus profit for the market. Risk reduction through exploitation of the body part and the patient consumer of the calculable risk puts the patient to work, who works in the illusion that the Master’s objective scientific knowledge, the ‘calculated risk’, is the ‘truth’ that guarantees or promises the fantasy of immortality, the limitless excess of life, the ‘surplus enjoyment’ of Lacan – in the capitalist Discourse of the University. The patient has a structure of discourse, his produce as a barred subject in an imaginary – his fantasy of a Master who knows, the knowledge he has to put to work, and the ?logic of scientific method, logos, with its circular logic, where effect produces its own cause – (like a diagnosis, even overdiagnosis the effect causes the presupposition that there was pathology that produced it originally, which is what makes it impossible to communicate overdiagnosis to a patient in a structure of discourse of the university – wedded to excess life or immortality.)

The crisis of EBM is the crisis of capitalism and relates particularly to (but not entirely to) the risks-markets. Preventive medicine or Precautionary Principle medicine.

This is why the core of EBM should be to question the truth of the available evidence not just to appraise it neutrally, the ‘evidence’ has economic and semantic values that function to produce excess, fantasy and a slave under the illusion of medicine’s mastery. The normalization of the use of calculable risk as a means of exchange to sell interventions for profit, puts risk on a homologous footing with calculable economic interest. It becomes normal to think of a risk as that which can be reduced without limit because it is normal to have no limits to the amount of profit that can be made when risk is calculable and equated to coinage. Where, as stated before, risk becomes symbolized by the loss of life that will be incurred if you do not buy the latest medical intervention, test or medication.

‘Belief’ in empirical evidence is founded in a belief in both the moral justice of the economic exploitation by capitalism – in Adam Smith’s invisible hand, and in Descartes God who produces the individual subject who believes in mathematised empirical logic as the ‘sole’ source of truth. Such faith leads to medical excess, surplus risk, as we are witnessing today.

 

The so-called crisis of Evidence Based Medicine,  it’s apparent exploitation by Capital causing over treatment is generally attributed to a nasty greedy misuse of the science, so that the ‘evidence’ itself is deemed to be faultless. And some have expressed frustration and a sense of helplessness. As a rule the EBM world pays lip service to ‘sociological approaches’ that try to see the patients care in holistic terms and to shared decision making, to limit coercion by industry. The EBM world tends to be ‘techie’ with a nerd like fascination with its maths, and derides suggestions that we may be subjects that are more ‘deceived slaves’ than ‘free masters’. In response to a recent thread I’ve posted this to the EBM Mailbase list, an academic forum.  So it will be interesting to see if there is any response.

EBM’s Moral Law:

I’m a UK GP now working in substance misuse, and have a background steeped in EBM , though less illustriously than JI, and I remember feeling ridiculed when I raised concerns in the 1990s at an educational conference on EBM in Oxford, where I was a tutor, about how to practice honest risk communication in UK general practice. This was deemed to be the GP’s problem and ‘not’ to be the epidemiologist’s problem.
Since then my disillusionment with EBM epidemiology has been deepened over the years by its legitimisation of intensifying public health preventive regimes such as cancer screening, health checks etc that intensify overdiagnosis, and EBM’s (ironically) patent opacity (it’s obvious ability to obscure its inherent uncertainties).
For several years I’ve been exploring what might be called critical theoretical approaches to try to understand what ‘makes good people do bad things’, and focusing on screening and prognostic diagnostic technologies relating to cancer.
For me the most important limiting factor may be how ‘Medical Practice’ can escape EBM’s ‘moral’ stance based upon its monogamous relationship with a (essentially capitalist and Cartesian) mathematicised empiricism and start an affair with politics, Marx, psychoanalysis, subjectivity, power, and fantasy.
These alternative theoretical approaches suggest that EBM hasn’t been hijacked; instead they would suggest that from its inception EBM has fetishised (excessively valued) empirical knowledge as part of a process (in a capitalist historical epoch) that ‘must’ create ‘biological difference’ (through use and exchange values eg through diagnosis) to produce surplus value (extension of life) that accepts as ethical and moral that man, woman and the body can be exploited for profit (by others) of either the economic or semantic kind – [a semantic ‘surplus value’ might be for example where the excessive valuation – fetishisation – of meaning of the word ‘cancer’ has evoked both obedient fear and a funding/research cascade].
EBM’s Moral Law might be expressed as: the justified exploitation of life through prognostic diagnosis to create surplus value out of life – this, is in other words, the ideology of a capitalist EBM, which is also a non-philosophy in that it’s truth is based on a dogma, and it’s exploitation hidden behind the fantasy belief in objective (and economised) empirical knowledge as the sole source of the truth that should guide medicine. At the same time, invoking expertise, as EBM does to reassure the sceptics, just adds to the problem as it is reinforcing the illusion that the expert is a ‘free master’ and not also a slave to this objective knowledge.
EBM’s crisis (in preventive medicine most acutely) is more fundamental than just financial invested interests (although these have a role to play). It is steeped in capitalist normative regimes that rely on unlimited growth and can only persist through ever intensifying and destructive exploitations of the body by ever more penetrative diagnostic and bio-racist technologies. EBM’s crisis also relies upon a subjectivity / a set of beliefs if you like/ that has to deny the possibility of mutual ownership (welfare, socialism), and that imagines him/herself to be a free master of his/her own decision making rather than a ‘deceived slave’ , and that believes his/her life can be extended and extended perhaps forever. Just as I do myself.
EBM, like gender, is a performative discourse, in other words, as a productive capitalist mechanism it enforces and normalises bio-racist roles and exploitative practices. The ideas of critical theory that links Marx with psychoanalysis and a theory of language as discursive power are used extensively by social theorists, feminists, queer theorists, colonial and post colonial theorists and political theorists. I believe medical practice also requires critical theorising, and critical discourse analysis as a (politically active) resistive intervention.
I have attempted to introduce these ideas to a (scientific) conference on overdiagnosis before but was rejected, as ‘not relevant’ – well it’s highly relevant. So I’ll try again and fail again no doubt , but fail better.

 

This is a rapid response letter posted to the BMJ in response to a suggestion that new diagnostic tests should come with a novel ‘net benefit’ statistic where experts devise decision curves that make explicit the choice of thresholds that determine the trade offs between eg the benefit of one new cancer diagnosis versus a threshold number of ‘several’ unnecessary biopsies or treatments. It’s not a ‘bad’idea in isolation but it has the effect of hiding the really critical problem of overdiagnosis which is the conquest of life by a neoliberal lawlessness:

 

References available on request.

The threshold might be better called an acceptable harm/benefit threshold; since the term : ‘net benefit’ already rhetorically loads attitudes to the test in favour of its use. It is however a good idea to make the trade off and the possible decision curves explicit in test research reporting. As a ‘statistic’ it still potentially misleads as it doesn’t tell you about (and even implies it doesn’t matter) the incremental value/harm of the ‘new’ test compared to existing care; and it also masks the opportunity cost of doing a new test that may be expensive and involve foregoing other aspects of healthcare, eg where there is a fixed healthcare budget. Clinical utilisation may also be profoundly influenced by the way tests results are presented and the thresholds for outcomes such as probability of outcome are chosen by test owners and researchers.

Some governments already preempt clinical decisions on harm/benefit ratio by the process of approving new technology for public expenditure by agreeing expenditure that has net population harms (measured by QALYs) because the opportunity costs are greater than the gains from the tests. NICE in the UK for example jusifities this by saying they must pay more to support innovative research and because the public likes innovation. The NICE financial threshold for approving new products is greater than the cost to save a QALY with existing healthcare so legitimises a hidden sacrifice of life in order to preserve the market in new technologies.

The major problem with the ‘net benefit’ statistic is the way it is being measured using expert judgements about population trade offs. There is a danger that experts in a specialist silo, are more likely than not to be ‘their chosen pathology’ risk averse, innovative technology friendly, and research publication enthusiastic. Experts are also (especially under extreme neoliberal regimes such as the USA) commonly constrained by contracts to follow clinical pathways sold to their employers under contracts with insurance companies who determine and authorise when (expensive) tests will be used.

The ‘net benefit’ approach may also be shutting the stable door after the horse has bolted since there is also the diagnostic research industry ‘ethical’ normative standard that demands a sensitivity of 90% (and never mind the specificity) and ‘astutely’ constructs artificial binary outcomes e.g. tests to predict cancer recurrence, that preempts any clinical attempts to judge harm/benefit ratios, since the test result is presented in terms of e.g. ‘eligible’ for further treatment and ‘directs’ decisions positively (ie is normativising to use a biopolitical term).

The arch psychological trap set for the patient is that as an individual you can never know if you might be the one saved or sacrificed which leaves you vulnerable to the fantasy that you are the one ‘chosen to be saved’ and therefore vulnerable to being objectivised by and subjugated to medicine’s neoliberal sovereignty.

This is a letter written to the British Medical Journal in response to a just published review of cancer screening studies (Prasad, Lenzer, and Newman, 2016). The review concludes:

“ The harms of screening are certain, but the benefits in overall mortality are not. Declining screening may be a reasonable and prudent choice for many people.”

i.e. that there is little or no evidence that population cancer screening reduces overall mortality – the authors call for more honesty, bigger studies and more ‘shared decision making’ .

These are all strategies that still ignore the post Kantian insights (by Nietzsche, Heidegger, Adorno, etc etc) that our concept of the individual as ‘Enlightenment Man’ autonomous and free to make his own choices is a Myth (Habermas, 1982) and the scientific method ‘reason’ functions as a comfort blanket to orient us to a life without beginning or end – and that there is (to paraphrase Foucault cited in Esposito’s ‘Bíos’, from ‘Nietzsche Genealogy and History’) always an

‘interval that separates the origin from itself, or better, from that which is presupposed in it as perfectly conforming to its intimate essence’ (Habermas, 1982; Esposito, 2008) p79

However the review of the lack of impact of cancer screening is a very useful article and should be widely read. Now, in response, I want to draw attention to the mutual dependence of a relationship between politics, life itself, and the ethics of always necessarily sacrificing some lives in order to preserve others.

My comment here explores the ethics of screening and predictive diagnostics from a (up til now) neglected biopolitical perspective. It introduces an academic domain that up to now has had little inter-disciplinary overlap with Evidence Based Medicine. And although some of the language and concepts here may seem a little esoteric I would ask you to persevere. This concerns the domain of Biopolitics. Biopolitics explores the relation, and the effects of this relation, between the political order (ideologies if you like, increasingly neoliberal today) and Bíos, a term used by Esposito to describe a biological life that objectives itself and is subjugated to the political order (Esposito, 2008a, b).

Medical screening to measure the risks of, and to prevent, future ill health is an example of what the Italian philosopher Esposito, in his book Bíos, has identified as an immunitary mechanism that functions, at least ostensibly, in the name of ‘preserving life’. (Esposito 2008a) However this function, Esposito claims, is only secondary to its primary function, which is to act as a kind of biopolitical glue binding together, (maintaining and reproducing) the political order (today – neoliberalism) with a biological life of a subject (bíos) that is subjugated to and is an object for this political order. Biological Life’s ‘ecstatic fullness’ (Nietzsche), innate instability and ‘will to power’ (Nietzsche, 1986) over time and neoliberalism’s demand for economic growth lead to an ongoing intensification of these mechanisms. The paper by Prasad et al (Prasad, Lenzer, and Newman, 2016) is a very useful demonstration of the coincident sacrifice and destruction of life that can only increase as the immunitary mechanisms intensify. Esposito might claim (on the basis of his writings in Bíos) that only the development of a new ethical relationship to life itself by the medical profession and patients, that begins to refuses the sacrifice of one life for another, will slow this process down. In addition a fundamental shift from neoliberalism’s dominance over medical practice could at least re-orient the impact of politics on so-called patients’ ‘values’- values not at present generated by the individual but constituted by a subject subjugated by the political order.

As in this paper by Prasad et al (Prasad et al., 2016) the resistance to such destructive mechanisms focuses mostly on regulation, bigger studies, ‘more honesty’ and shared decision making (SDM). But we can see that these, alone, can and will never succeed in preventing an increasingly destructive (even thanatopolitical) process. These strategies may even function, given biopolitical politico-economic imperatives and power, to legitimate further intensifications in the longer run.

These resistive measures do not address the biopolitical and therefore the structurally neccessary ‘tremendous prophylactic’ (Nietzsche 1986) p113 immunitary drivers that maintains the subjugation of the population necessarily and reciprocally bound to and maintaining the existing social order and its socio-economic inequalities.

“….. against the vacuum of sense that opens at the heart of life that is ecstatically full of itself, the general process of immunization is triggered…. ‘the democratization of Europe is, it seems, a link in the chain of those tremendous prophylactic measures which are the conceptions of modern times.’” (Esposito, 2008a) p89, cites (Nietzsche, 1986) p113

Yes, medical practice, sometimes ethically, prevents suffering more or less in two ways a) the suffering today and b) preventing suffering tomorrow. But is it always ethical if it involves sacrificing one life for another, and when an individual does not know whether his body is being preserved or sacrificed or even both? Resistance to the excess of destruction is an important but biopolitical struggle. However the efforts by those resisting screening’s excesses focus on a struggle that is not seen for what it is. On the surface are the effects of systems using forms of biological knowledge in a struggle between a) interventions for profit and power, and b) non-intervention – sacrificing power and profit. But this is secondary to the primary biopolitical prophylactic (immunitary) imperative to ‘preserve life’ that results in the struggle  between a) preserving an anticipated future life by eradicating risk, versus b) allowing a life today to take its chances and face risk, or if you like between preserving by sacrificing life or nor preserving life. Preventive screening and predictive medical interventions can either preserve life now or life in the future but either way must entail more or less sacrifice, destruction and weakening of life. New questions, language and strategies for medicine can emerges from Esposito’s writings such as: Is the intervention necessary? is it always ethical to weaken one life in order to strengthen another? Is it ethical to divide lives ‘worth living’ from ‘lives not worth living’ on economic grounds?

The French doctor and philosopher (and resistance activist fighting the Nazis) Canguilhem introduced the idea of ‘normative man, where life itself is its own norm; clearly not a panacea in itself but worth consideration:

“health is in no way a demand of the economic order that is to be weighed when legislating, but rather is the spontaneous unity of the conditions for the exercise of life.” (Esposito, 2008a) p189 citing Canguilhem ‘Une pédagogie de la guérison est-elle possible?’ In ‘Écrits sur la medicine’ (Paris editions, du Seuil, 2002, p89)

My final comment (not included in the letter to the BMJ) is a half formed problematic: if Man must have a Master, if Man can only change the object of his desire but not manage without one, then how can man become Canguilhem’s (and Goldstein’s) ‘normative’ man, where man creates his own norms? Perhaps a way forward might be to bridge a couple of gaps towards Annemarie Mol’s ‘Logic of Care’(Mol, 2006) – where the acquisitiveness and envious aggression of the Hobbesian individual is replaced by an object of desire that is precisely the natural expansiveness of the virtual ‘a’ life, and that requires a giving up of individual identity in favour of a collective ‘life’ that is trans-historical – so that the individual is just a temporary free-loader, on the bus of the life with no beginning or end for a little while, then just jumping off. Is there a political imperative here that rejects liberalism as that which coerces us into the constant state of war we are experiencing in the world today? Mol states:

“In the logic of care flesh and blood do not imply determinism. This is because, while knowledge from the natural sciences is mobilised in the consulting room, it is also given a new assignment. It is not asked to explain what the world is like, but asked to suggest what might be done. It is made to answer practical questions.” P43

However there is a problem here.  We can see that the imperative to ‘do something’ must be a normative technique that silences the thought of the subjugated. In preventive medical terms one ends up saying: “I was just following orders”  – leading to an Arendtian banality of evil (or even, to be speculative: a troop-like self-interested and self destructive banality of benevolence).

The question posed as ‘practical’ here has its roots in the semantic declension of ‘ethos’ from the Greek: the ‘nature spirit or culture of a society or community’. In this transformative declension  ‘ethos’ becomes, today, what is determined as ethical by a juridical-political moral code that even determines the questions that should be asked and excludes those that shouldn’t. The (practical) question that ‘must’ be answered by the test of, or in the consultation about, preventive medicine hides what must not be asked for i.e. ‘an explanation’ for the question.  It hides a modern bio-ethical ‘ordering’ (or normativisation) in the name of ‘preserving life’ which hides the immunitary mechanism that holds self-objectivised  subjects in subjugation to the neoliberal political system and its inequalities (and orients us in a world of infinitude). But how? The mechanism works through the presupposition of responsibility and a guilt for harbouring an alien pathological ‘other’ ‘flesh’. Here, we can see there is a permanent infolding of the self in the form of multiple and ever present corporeal infestations.

This is the ultimately thanatopolitical immunitary semantic declension from ethos to ethics  that is not solved by Mol’s ‘Logic of Care’ and requires the ethos of the self to be re examined.

Esposito, R. (2008) Bios: Biopolitics and Philosophy. Minneapoli: University of Minnesota.
Habermas, J. (1982) The Entwinement of Myth and Enlightenment: Re-Reading Dialectic of Enlightenment. New German Critique, 26: 16.
Mol, A. (2006) The Logic of Care – Health and the Problem o Patient Choice. Abingdon: Routledge.
Nietzsche, F.W. (1986) Human, All Too Human. A Book For Free Spirits. Cambridge: Cambridge University Press.
Prasad, V., Lenzer, J., & Newman, D. (2016) Why cancer screening has never been shown to “save lives”—and what we can do about it. BMJ, 352.

Dear Mr Mulholland,

Thank you for the e-mail. I am extremely disappointed in your vote and your justifications.

You make several dubious assertions:

It is not at all obvious that it is a good thing to get rid of Assad, dictator though he is we have seen the consequences of removing a similar dictator Saddam Hussein in Iraq. It seems reasonable to look at Iraq’s fate at the hand of western sanctions and what happened after Iraq’s invasion. Even today Iraq has millions requiring humanitarian aid, and thousands of children died as the result of sanctions before the invasion.

Approximately 3.3 million Iraqis, including 750,000 children, were “exterminated” by economic sanctions and/or illegal wars conducted by the U.S. and Great Britain between 1990 and 2012, an eminent international legal authority says. http://www.globalresearch.ca/us-sponsored-genocide-against-iraq-1990-2012-killed-3-3-million-including-750000-children/5314461

And ask yourself, did getting rid of Saddam really help the people of that country? Today in Iraq:

An estimated 8.2 million people across Iraq remain in need of humanitarian assistance, including Internally Displaced People (IDP), Syrian refugees, returnees and host communities, as well as affected populations in Armed Opposition Group (AOG) held areas. http://reliefweb.int/report/iraq/unicef-iraq-monthly-humanitarian-situation-report-1-31-october-2015

If the same circumstances are repeated in Syria, and Syria like Iraq and Libya become western puppet caliphates like Iraq then there is a real danger that further bombing in Syria will contribute to catastrophic numbers of deaths in that region. There is also much doubt about the extent of the crimes of Assad’s regime: see for instance the introductory chapter of Professor Tim Anderson’s forthcoming book entitled The Dirty War on Syria:

http://www.globalresearch.ca/the-dirty-war-on-syria/5491859

ISIS as Obama recently claimed and as I understand it received initial impetus from the chaos that resulted from the Iraq invasion in 2003, not from Assad. And the civil war in Syria may also not be laid entirely at Assad’s door. It is quite possible that the civil war in Syria was in part stimulated by western backed military support and funding for the Free Syrian Army and other such Islamic groups. This seems even more likely given that in 2013 Cameron’s government wanted to bomb Assad’s troops and support the FSA.

Stating that a reason for voting for a lethal bombardment and the deaths of innocents is in order to maintain a western coalition of powers is shallow, unless you can justify the lethal bombardments of those other powers such as France. Also, I haven’t heard any argument suggesting that bombing in Syria will reduce the risk of blowback attacks in the UK, and after all the people who may inflict such acts may well already be in the UK.

You are either ignorant of or wilfully ignore the role of such countries as Saudi Arabia and Israel in fostering the break up of Syria. See:

Zionist Benn’s Grab For Power

You have voted for an amplification of a logic of destructive ‘self protection’ that will lead to an acceleration of a violent global ultimately global catastrophe.

I leave you with this conundrum:

The stoning of a woman for adultery in Saudi Arabia and our mainstream media’s lack of interest in it makes one think, or it should:

Please see:

http://wearechange.org/saudi-arabia-is-about-to-stone-a-sri-lankan-woman-to-death/

Q.

1. Why is the ‘west’ so keen to a) be an ally of Saudi Arabia and b) to get rid of Assad in Syria?
2. Was/Is Syria ‘too independent’ of western (oil) corporate interests?
3. Does the west need a threat to attack because the ‘west’ (neoliberalism) is formed and continues on the basis that its formation and development was in response to a presumption of an always already existing threat of attack.

But trying to the kill off the threats must kill the innocent thereby fanning the flames that will in the end kill the host.
This is Esposito’s immunisation paradigm – an example of a thanatopolitics (a politics of death) in action. (Esposito, R. (2008) The Immunization Paradigm. diacritics, 36(2): 23-48.)
There IS a viable alternative: challenge the US/Israel/Saudi hegemony that fosters ISIS and the break up of Syria, through effective diplomatic, political and economic means. Join wth Russia to re-stabilise Syria.

Challenge the neoliberal negative use of the concept of ‘freedom’ which insists all must be free to not be threatened by the other. This stimulates greed, violence and ultimately self destruction

Sincerely

Owen Dempsey MRCGP

6 Castle Grove Drive

Headingley

LEEDS

LS6 4BR

07760164420

On 04 December 2015 at 15:35 Greg Mulholland <greg@gregmulholland.org> wrote:

I am writing to you in relation to the recent debate and vote on regarding air strikes in Syria.

After lengthy consideration and discussion, I decided, as did my party leader, to vote for the Government motion to extend current air strikes against ISIS/Daesh in Iraq to also strike ISIS/Daesh in Syria. This must be part of a wider diplomatic and military plan to tackle this monstrous enemy, resolve the Syrian conflict and help end the refugee crisis.

This is clearly a very difficult decision, but in the end I have been presented with no viable alternative other than to work with the international community on a diplomatic and military strategy that involves action in Syria as well as Iraq.

The RAF are already targeting ISIS/Daesh in Iraq. It needs to be understood that what we are voting for is for the RAF to join French and American allies- and Russia- to also target ISIS/Daesh in Syria. The UK is already using air strikes against ISIS/Daesh in Iraq, with the support of the Iraqi government and assisting their army in defeating this evil force. That is the right thing to be doing. What we are now discussing is whether to extend these air strikes to Syria as part of a wider international strategy.

People are comparing this decision with the possibility in 2013 of the UK attacking the forces of Syrian dictator Bashar al-Assad, but this is clearly not the same, legally or in reality. That potential action was taking on an existing ruler, this is not. It is targeting a terrorist force that is murdering, subjugating and raping thousands of people in Syria and Iraq. They have also beheaded British aid workers and thrown gay people off buildings. Now they are targeting Western Europe and people enjoying a rock concert or a meal with friends because somehow that is all about prostitution and homosexuality. This is an attack on our way of life, our shared belief in democracy and tolerance and everything this country fought for. We fought against a similarly monstrous illiberal movement, the Nazis who also persecuted and killed people due to their religion, nationality, race or sexuality.

As an internationalist party, we accept our responsibility to assist with international peacekeeping efforts. At times, when done legally (which this would be), we must also support international military action against those who terrorise, suppress, and are involved in mass murder and rape.

I fully accept that bombing alone will do little – but the point that people simply saying “don’t bomb Syria” are failing to grasp is that the US, France, and (crucially) Russia will work with us on a post-Assad future for Syria, but these countries do expect us to play our small part (which is what it is) in existing military action against ISIS. This is now about a wider solution and not about a few token missile strikes.

I am clear that this is not about “bombing Syria” or even just about dropping a few bombs on ISIS/Daesh targets. I agree that alone would not do much to alter either their position or the civil war. The actual motion we are voting on is not “should we bomb Syria”, it is a commitment by the United Kingdom to be part of – and play a full part in – an international a wider diplomatic and military solution, so it is wrong to misrepresent what we are voting on. The actual motion MPs will be voting on is:

“That this House notes that ISIL poses a direct threat to the United Kingdom; welcomes United Nations Security Council Resolution 2249 which determines that ISIL constitutes an ‘unprecedented threat to international peace and security’ and calls on states to take ‘all necessary measures’ to prevent terrorist acts by ISIL and to ‘eradicate the safe haven they have established over significant parts of Iraq and Syria’; further notes the clear legal basis to defend the UK and our allies in accordance with the UN Charter; notes that military action against ISIL is only one component of a broader strategy to bring peace and stability to Syria; welcomes the renewed impetus behind the Vienna talks on a ceasefire and political settlement; welcomes the Government’s continuing commitment to providing humanitarian support to Syrian refugees; underlines the importance of planning for post-conflict stabilisation and reconstruction in Syria; welcomes the Government’s continued determination to cut ISIL’s sources of finance, fighters and weapons; notes the requests from France, the US and regional allies for UK military assistance; acknowledges the importance of seeking to avoid civilian casualties, using the UK’s particular capabilities; notes the Government will not deploy UK troops in ground combat operations; welcomes the Government’s commitment to provide quarterly progress reports to the House; and accordingly supports Her Majesty’s Government in taking military action, specifically airstrikes, exclusively against ISIL in Syria; and offers its wholehearted support to Her Majesty’s Armed Forces .”

So I and we would not vote simply to drop a few bombs and if that is all it is, we would not support it. But if us extending our air strikes already happening in Iraq to over the border in Syria is a necessary part of a wider international solution, then we are prepared to and will do so.

I am also very clear that to disrupt and defeat ISIS/Daesh not only clearly involves concerted legal international military action, but in the end will involve ground forces. The question is whose ground forces and this is where we need existing ground forces getting more support and training. We will also need potential involvement from a Middle East-led international force, rather than Western forces being involved.

Of course I understand the concern and the views of those who say we should not extend our military involvement in Iraq to Syria. However I have heard no realistic alternative strategy of how we take on this monstrous anti-democratic, murderous and grotesquely intolerant, illiberal force. So in the end, I am voting to support concerted action rather than doing nothing, because doing nothing will not stop ISIS/Daesh and stop them we must.

We also must act as an international community to stop the Syrian civil war. What many Syrians ultimately want is the Assad regime gone. We must never lose sight of this being our end goal, so Syria can be ruled by a democratic government chosen by Syrians themselves, not a brutal dictatorship run by one family. And as long as Assad exists, ISIS/Daesh will continue to recruit. I, and indeed the Liberal Democrats, have always been clear that air strikes alone are not a solution. We also need to find a way to remove Assad, and this was touched on in the second of the five criteria Liberal Democrats lay out for supporting airstrikes. The question is how we remove Assad, and being totally realistic, the Vienna talks are our best chance right now. Whether we like it or not, there is no other option and I would challenge others to suggest one.

Yes, the Vienna talks have their issues – mainly, that Syrians aren’t represented. But my office has spoken with the foreign affairs minister responsible for the Middle East, Tobias Ellwood MP and I understand that a UN group is present at the talks looking specifically at inviting a broad range of Syrian representatives. This is an important task since the Syrian opposition forces are much divided and exist in many factions, so we must seek to involve as many of them as we are able to. Tobias Ellwood MP said clearly that “Syrians must be involved” in these talks. It is only right that the future of Syria is decided by Syrians themselves, so I look forward to them playing a leading role in the Vienna talks as they develop.

Regardless, as I have said, the Vienna talks are our best chance right now to remove Assad. Then the question is, doesn’t that depend on Russia no longer propping him up? Indeed, and Vladimir Putin knows he is risking extremist instability within Russia the longer he allows ISIS/Daesh to grow. In short, Vienna could be Russia’s own exit route from having to back Assad. This is significant. The Vienna talks are proposing a six-month political transition, led by parties that both the regime and opposition agree on, followed by an 18-month timetable for elections. There are caveats with the Vienna talks but, and I labour the point deliberately, they are our best chance of removing Assad and that will remove the main driving force behind the creation of ISIS. The Holy Grail is Assad and ISIS gone, and Syria put back in the hands of Syrians, allowed to rebuild and look ahead to a better future.

Our international partners expect us to play a full part in the action required to take on ISIS/Daesh, if we do not do so, we will play little if any role in also assisting with a solution to the civil war and a stable and democratic future for Syria. So I do believe that to be part of the wider solution, as we clearly should, we are obliged to also play our part, our small part, in the air strikes on ISIS/Daesh in Syria as well as in Iraq.

As I have said, bombing on its own is not the solution and the House of Commons vote must not be seen that way. We also need to understand that the refugee crisis- the worst we have seen in Europe since the Second World War- will not be solved unless the Syrian crisis is resolved. To do this means a wider strategy to ensure a safe, stable and democratic Syria and the removal of ISIS/Daesh who have forced thousands to flee their homes and an end to the civil war that allows them to operate as they do, as well as an end to Assad’s oppression. I and the Liberal Democrats have been right to call for us as a nation to do our bit to assist those feeling persecution and violence, but in the end it is hollow to do so when doing nothing to tackle the reasons for the people being forced to be refugees in the first place. So we must get to the situation where hundreds of thousands of Syrians are not having to abandon their home country and seek refuge elsewhere.

Yes, we must continue to show our compassion to people in desperate need- imagine being in their shoes. But Syrians, like each of us, want to live in their own home country, not be driven away from it. So while resettling Syrian refugees, we must also work to get the stability in Syria itself. Remember, these refugees had their family, friends, jobs and schools in Syria. They will want to try to return to that and rebuild the lives they had. It is therefore not enough to simply call for resettling refugees when we all know the only solution is this: a stable Syria that millions of people do not have to flee from in the first place. That must be our ultimate goal that we work towards and I see my decision as part of that.

So I hope that explains my position and how I and colleagues have come to this very difficult decision. I accept that people will have different views on this, but those of us making the decision are the ones who have to actually vote on the motion before us and it is a decision that whatever we do will weigh heavily upon us, as it must, but I and colleagues will do what we think is the right thing for the country, as either way it will it will be difficult for the party.

—
Yours sincerely

Greg Mulholland
Member of Parliament for Leeds North West

Tel: 0113 226 6519
http://www.gregmulholland.org
Twitter: @gregmulholland1

Whilst Greg Mulholland will treat as confidential any personal information which you pass on, he will normally allow staff and authorised volunteers to see it if this is needed to help and advise you. He may pass on all or some of this information to agencies such as the DWP,HMRC or the local Council if this is necessary to help with your case. Greg Mulholland may wish to write to you from time to time to keep you informed on issues which you may find of interest. Please let him know if you do not wish to be contacted for this purpose.

An introduction to predictive diagnostic epistemology and a mandatory yet impossible ‘biological normality’

By Owen Dempsey 

 

It is an age old commonplace  that we live in an age of anxiety, consumerism and inequalities. But it is a more recent commonplace to argue for Patient Power : that a responsible citizen should take more responsibility for the measuring and budgeting of her own health. Perhaps, if you are wealthy enough you should get a fitness app, apply for a personal health budget, buy shares in molecular diagnostics, purchase your blood tests, PET scan and your genetic profile  for just 1000$, and dutifully go to your family doctor for a ‘health check’. But why?

What isn’t so common is to question the basis of these activities, to ask what it is that we are aspiring to here.  Is this aspiration something called ‘health’ or ‘normality’: the so-called normal healthy state that we should aspire to be?  Our contemporary apparently obvious idea of the ‘normal is in fact steeped in 19^th Century concepts of the pathological as just a variation of normal physiology. But in everyday life this has led to a contradiction since if they are qualitatively the same how can we tell them apart? I am suggesting here that this contradiction underpins Evidence Based Medicine’s major problematic: the identification of and quantification of biological difference to identify the  future  risk of biological precarity.

George Canguilhem’s harsh take on the reality of health as an inevitably perpetually declining power, from the start, to resist danger, is defined later on. But we know the markets don’t want to hear such negative attitudes, after all cures make money.

Much political rhetoric attempts to seduce us with the concept of aspiration, e.g. the freedom to buy a house, to have your own personal health budget, and so on.  This rhetoric is that of a neoliberal politics, where the freedom for the individual to aspire to the greatest heights is paramount, apparently free of government interference, but with the support of a free competitive market.  This freedom is ‘shaped’ (a phrase used by Hayek, a reactionary economist and advisor to Thatcher’s government in the UK in the 1980s), but it is an illusion of control. I would argue (after Jacques Lacan the psychoanalyst ) that instead of freedom, the individual is being set adrift in a fragmenting-society of apparent limitless possibilities and potential for growth.  This endangered individual suffers a subjective psychic breakdown, loses anything remotely like aspiration and instead experiences a sado-masochistic servitude, a form of masochistic slavery to the sadistic market.

The idea here is to look at what the idea ‘normal’ signifies. Briefly, we will find to our surprise that it is a slippery complex and ideologically powerful customer!  For Galton it was a mediocre average (this leads to eugenic overtones eventually).  For Quetelian (and the conservative Durkheim) the normal was an arithmetic mean, and something to which we should aim to be restored, a kind of baseline. For Canguilhem, the French philosopher and historian of science (they amount to the same thing in France) the medical ‘normal’ is an Aristotelian virtue, and in terms of goodness or excellence it is an extreme perfect ideal to be aspired to.  In theory this perfect but impossible ideal stems from Broussais’s principle (another Frenchman, this time a physiologist) who in the 1800s maintained that anything pathological is merely demonstrating a qualitative deviation (excess or deficiency) from something that is normal. This was a principle taken  up by the infamous positivist August Comte who applied Broussais’s principle to the social and so felt able to define moral deviancy.  The two most difficult and subtle points here, hard to grasp, are that a) because pathological tissue is qualitatively the same as the ‘normal’ it is then impossible to derive a quantitative measure to show that the pathological and the normal are actually different (and thereby to identify and define a ‘normal’); and b) by measuring difference we invisibly imply that there is a norm, and it is one that we should be aspiring to.

Here is an attempt at a hypothetical example, suppose that we classified means of transport perhaps in terms of engine size or number of wheels, and we discovered that large engine sizes or numbers of wheels were associated with more accidents.  We could say that for example 16 wheeled vehicles were definitely dangerous and should be banned, but at what point, how many wheels, would you say that a means of transport was ‘normal’  was OK and did not require any special measures. There is no measurable (quantitative) number of wheels that enables us to separate one class of vehicles from another in terms of their qualitative form. All means of transport no matter how many wheels are risky, but counting wheels signals a desire to eradicate risk. You can imagine that if there is profit in persuading people that fewer (or smaller, or with fewer bearings, or titanium bearings, or harder/softer rubber etc etc) wheels might be safer, always just a little bit safer, then with a bit of effort and imagination you may start to get a feel for the economic market power of molecular diagnostics. Your body has a kind of wheel (genome) that embodies the risk of transport: the biological precarity of life. There is no lower limit to our ability to dissect this wheel (genome) and quantify your risk and the market and science will invent tools to construct these differences to sell for profit.  I think I’ve stretched this metaphor perhaps too far but I hope it might help.

So by extension to the life-world we would say there is no measurable biological characteristic that enables us to separate the pathological tissue from the normal. And yet each of us is under pressure to consume and submit to screening diagnostic tests (a form of wheel counting, that make profits for doctors and business), precisely to measure differences that confirm our pathological abnormality, our risks of future illness, and by doing this it presupposes that there is a ‘normal state’ and it demands that we must aspire to it.  Thus biological normality is both mandatory and impossible.

Foucault in his ‘Birth of Biopolitics’ and ‘History of Sexuality” describes this situation arising because of the ‘will to know’, a  more or less political regulation of a market, a will to measure and normalise a population’s morals and health, identify deviancy etc, a classification of diseases based on organ ‘deviancy’ or pathology, and following Husserl in his ‘Crisis of the European Sciences’ a philosophy of knowledge that has mathematised and lost its original connection with nature.

The main sources here are Husserl’s phenomenology, and Canguilhem’s ‘The Normal and the Pathological’, Foucault and with a supporting role for Ian Hacking’s ‘The Taming of Chance’:

Fascinatingly Edmund Husserl, a Moravian mathematician turned phenomenologist, argued in the 1930s that Galileo had developed mathematic models to try to explain nature and that this led to the development of ideal perfect geometrical concepts, all obeying mathematical formulae.  This in turn developed  into a deeply held conviction that nature must obey mathematical formulae, and that nature in its reality somehow obeys these ideal perfect geometrical constructs. The original meaning of geometry as only a useful model representation of nature was forgotten. Husserl’s key point is that the original meaning of the concepts which is the attempt to provide a coherent framework for the mass of observed data ( a method for generating knowledge called induction), via human perception of course, has been forgotten and instead the maths and geometry has become the founding basis of what we believe nature to actually be.  I think that in an identical fashion current scientific positivism and what we can call classical Evidence Based Medicine (EBM)  has been based on a forgotten method of induction: the collection of large amounts of data followed by an attempt to mathematically classifiy.  What is also forgotten is that our sense of these classifications representing reality faithfully, the  ‘ideal’ as in abstract constructions of pathological entities and by implication the normal biological state is also the result of human sense constructions.  So Husserl, put simply, sought to reframe knowledge by basing it on subjective perception alone not theoretical mathematically based theory.

Scientific positivism presupposes a ‘normal’ that is signified by August Comte’s aspiration for an  ‘ideal’ or perfection, an extreme Aristotelian ‘virtue’, in terms of goodness and excellence. Comte’s appropriation of the ‘normal’ for social means enabled the ‘normal’ to be  simultaneously used as an arithmetic mean, as well as  a state we have ‘fallen’ from, and also ‘aspire’ to, and a symbol of  acceptable, non-criminal, morally correct human nature/behavior).

So, for example, in social terms obesity, Heroin addiction, alcohol dependency, refusing to vaccinate your children, refusing cancer screening and health ‘checks’, are not ‘normal’ which is a signifier presupposed by and resulting from the diagnosis of any ‘pathological state’ and signifies at least three things simultaneously as a ‘shape-shifter’.

The abstract idea of Pathology presupposes three things :

1. a arithmetic mean of a distribution of a measureable biometric, a mean defined as ‘normal’
2. a ‘normal’ (right, correct, good) baseline state to which we must be restored and
3. a demand to aspire to a fantasised ideal extreme virtue of a state of normality that is risk and precarity-free.

So the ‘normal’ can be and is simultaneously: a desirable average, a state to which we must be restored, and an ideal perfect state to aspire to.

This ‘sliding’ signification is part of what gives ‘normal’ and  its significations such ideological potency. So observers can say: ‘but of course there is such as thing as a ‘normal’ for a population, its just the mean, so your talk of an ‘impossible normal’ doesn’t make sense.’

The detection of future risk of pathology, in terms of cancer as an example here,  results in measurements which are:

1. put in terms of a human construct: the language of risk (‘low risk’, ‘high risk’ etc) that functions within societal contexts of discourse (e.g. the market, screening programmes or consultations or NICE guidelines), and
2. a symbolisation of risk that concerns another human construct: a pathology called ‘cancer’ that certainly causes suffering but is also certainly complex, unpredictable in terms of outcomes and responses to treatment or lack of treatment, and that as a human perception has a limit, a point where cancer becomes non-cancer, and I believe this is a limit that is not objectively measureable or at least has not been objectively measured as yet; and
3. a symbolisation for the necessary treatment of a ‘risk’ of ‘cancer’, (so we have a third level of meaning-fulfilling conceptualization here, where each level only compounds the rhetorical effects and increases the subjectivity of the meaning fulfilled).

This also represents an unknown for an individual in four senses:

1. the individual won’t behave according to the population norm since this is an ‘ideal object’ too, and
2. the measurement of harms versus benefits is statistically error prone too, and always excludes precision for any individual
3. following Husserl, harm and benefits are part of a whole life that is not totally measureable
4. the nature of the aspirational ‘ideal’ normal state –

So, as a schematic simplification, and using the example of  cancer risk,  the four layered question might be, for an individual,

1. to what extent can your individual risk be measured for developing
2. something ‘ideal’ (abstract) called ‘cancer’ that may or may not be harmful, and
3. that may or may not benefit from medical treatment
4. and that presupposes a mandatory but impossible risk free biological normality?

This is the four layered question forced to emerge by the predictive screening test for e.g. a cancer development or recurrence at some time in the future.

The proposed solution for healthcare, the object of preventive medicine, is the demand for the impossible identification of ‘the’ risk that determines whether medical intervention is worthwhile for an individual. Instead of being a solution I am suggesting that this is EBM’s problematic. The fantasy (imaginary possibility of cure) veils this impossibility (symbolic precise knowledge of risk) that emerges as the Real (e.g. revealed by the inconsistencies in the naming practices of borderline diagnoses in breast cancer screening, such as: indolent tumours, to premalignant lesions, to ductal carcinoma in situ).

The fantasy also veils the impossibility of ever being able to eradicate something, e.g. a pathology like cancer, a pathology that is a precondition for the  possibility of diagnosis, since diagnosis is based upon the necessary presupposition of an  always already present pathology.

The fantasy (as fantasy always does according to Zizek) also contains the obstacle to its realization in terms of a Law, a Rule, which for Society is a Rule concerning the need to find cancer early in order to cure it.  In other words, even if a risk could be ascertained as valid knowledge, its ‘truth’ would be undermined by the imperative to investigate in order to diagnose cancer as early as possible to the point where cancer must be diagnosed where nothing like cancer exists. In other words for cancer to be diagnosed as early as possible there must be no lower limit to the risk at which investigation is required or to the tissue appearance that may be ‘cancer’. The body under a neoliberal or anarcho-radical-liberal governmentality (politically and economically deregulated but individually highly regulated) must always be already biologically precarious, or indeed cancerous.

You might argue that all this talk of aspiration only applies to a small wealthier section of society who can afford to worry about their future biological risk or precarity. But there are broader societal implications. Healthcare costs are in danger of becoming increasingly dominated by a neoliberalised ‘diagnostic moment or test’ led health economy aided and abetted by the classical EBM community, driven by increasing demands for screening and health checks  for the ‘healthy’. This may well a) reduce the money available to provide care for those who are ill, disproportionately represented by the poorest in society, and b) drive down the opportunities for health for the poorest, those with the greatest need, increasing health was well as social inequalities.

I like the quote from Canguilhem on health:

“The life of the individual is, from the start, a reduction in the power of life.  Because health is not a constant value, but the a priori of the power to overcome dangerous situations, this power is one which erodes through the mastering of successive dangers.  Health after cure is not the same as before illness.  A lucid awareness that cure is not return can help the patient’s quest for a state of least possible renunciation, by freeing him or her from a fixation on the earlier state.”

(Une pedagogie de la guerison est-elle possible 1978 17, 13-26)

You don’t aspire to be normal. Instead it is a concept, the ‘normal’ that aspires to consume you!!