LOGICAL POSITIVISM IN THE 1950s and its influence on The Philosophy of EBM

The corporate medical establishment loves ‘Evidence’ and claims this is only contaminated by talk of ideology: Thus in an editorial in 2005:

Each side of the NHS debate accuses the other of being driven by ideology, without seeing that ideology is equally evident on both sides. Ideology makes things simple when in reality they are irretrievably complex. The private finance initiative (PFI) may have seemed ideologically sound but its lack of flexibility has stymied it in practice (p 792)—an expensive mistake. Meanwhile the new pressure group “Keep our NHS public” tends to ignore the inconvenient fact that the NHS has always worked with private practitioners.BMJ 2005;331:0-h

This misunderstands ideology which is most easily captured by the phrase ‘normative preference. The basis of Evidence Based Medicine is an empiricist logical positivism, so this article is a look at logical positivism’s logic through an article by Rudolf carnap in 1950.  It shows that the theory is great but in practice the names given to things or to abstract concepts are accepted and used on the basis of their context and their intent. Language is a social and economic tool that disperses power and subordination.

Rudolf Carnap, of the Vienna Circle, was responding to neo-Kantian controversies, Kant had distinguished between the sense-perceived and human constructs such as space and time and had postulated an intermediate epistemic mechanism that enables us to make ‘knowledge’ out of these two things, this intermediate mechanism was disputed by philosophers after Kant in a neo-kantian debate. Carnap I think denied any need for any intermediate epistemic mechanism but thought knowledge should only be based on an ‘accepted’ use of language, and was quite happy for empiricist nominalists to use abstractions as long as they didn’t believe these represented anything in the thing world.

The fly in his ointment is the idea that knowledge should be ‘based on language’ which presupposes that language itself can provide or determine all knowledge that can be known, i.e. language as having determinate meaning.   This is a decision that has profound ideological consequences, and emphasises just how important ideology is to the practice of medicine and how it determines was evidence is both generated and ‘accepted’.

Carnap  disagreed with Wittgenstein about the nature of logical syntax, for W this was only ever a display of what there is out there, for C this is ALL there is, any other questions are meaningless, C did away with metaphysics, his essay  is an important foundation for logical positivism and therefore important for EBM philosophy, EBM seems to have adopted Carnap. Bachelard et al, suggested that as the forms change historically so does knowledge.

http://www.ditext.com/carnap/carnap.html

“Empiricism, Semantics, Ontology”, Revue Internationale de Philosophie 4: 20–40. Carnap, R (1950)
But logical positivism leads to Zeno’s paradoxes, the asymptotic impossibilities, and I wonder if predictive diachronic diagnostic processes based on logical positivism also leads to a Zeno’s paradox, the impossibility of biological normality. Why put the logic of syntax on such a high plane so as to discount anything outside language like an unconscious, and psychic drives of alienated mortal traumas, of the symbolic castration – precisely the metaphysical I think.

So, for the practice of medicine,  an issue becomes whether a diagnosis named, the abstract term is of a real object or an abstract entity, does it represent a reality ‘out there’ or is it a human abstract form of thought. Is this a big question? Why would Carnap dismiss this, if he would? For nominalism, the abstract term exists, such as tree, but the abstract universal tree, the abstract object does not exist, this would be the metaphysical. The abstract. A borderline cancer is an abstract term, it exist but the universal abstract ‘borderline cancer’ does not exist, its an abstraction, it has no physical referent. Is this a problem for logical positivism? To repeat: better; nominalists do not believe that there is any physical referent for a universal abstract term, like a tree, or the colour green; whereas a realist might believe there is something physical that is common to all the universals, even if it is at the level of some kind of fundamental particle. OK – thought, to reject the metaphysical is to reject ideology, and Foucault’s sense of subjective transformations in history through a changing balance between egoist and collective interest in interests, or governmentalities. Ian Hacking says the positivists and the ‘social constructionists’ shout past each other.

The BMJ says “Evidence not Ideology”. Wrong, my challenge. “Evidence is ideology writ large” Naming Difference is an act with an egoist economic motive, and motivated by a more or less liberal political economy, to produce a product for a more or less free market economy, an act of more or less self-investment.

Carnap says empiricists more in sympathy with nominalists, ….. suspicious of abstract entities, like properties and class relations, experience perceived and felt, “My Body, this paper, this fire” is the thing. And yet, the EBM empiricists deal in abstract terms and objects all the time, so are they realists, or nominalist and does it matter? A pure empiricist should not deal in abstractions then? I think Carnap argues against this.

‘Accordingly, the mathematician is said to speak not about numbers, functions and infinite classes but merely about meaningless symbols and formulas manipulated according to given formal rules. In physics it is more difficult to shun the suspected entities because the language of physics serves for the communication of reports and predictions and hence cannot be taken as a mere calculus. A physicist who is suspicious of abstract entities may perhaps try to declare a certain part of the language of physics as uninterpreted and uninterpretable, that part which refers to real numbers as space-time coordinates or as values of physical magnitudes, to functions, limits, etc. More probably he will just speak about all these things like anybody else but with an uneasy conscience, like a man who in his everyday life does with qualms many things which are not in accord with the high moral principles he professes on Sundays.’ (p20, my bold)

Could we substitute ‘medicine’ for ‘physics’ in the above, and are the limits of physical magnitudes uninterpretable for the empiricist, such as the degree of abnormality of a tissue appearance, as an abstraction communicated in a pathology report. It sounds as though Canap is going to contradict this, so an important paper. It may be that normality is an abstract term, and does not exist in fact, therefore an empiricist evaluative investigation to detect spatio-temporal facts or events that rely upon an opposition to the non-existent normal must be flawed. The impossible question for medicine is not; “Is that tissue inflamed?” but “Is that tissue normal?”

Carnap’s empiricism seems to ignore the way language functions to disperse power through the construction of the objects of which it speaks (after Foucault), it also seems to ignore the contradictions and paradoxes that occur within the thing language, whereby e.g. several different names are given to (and function in respect of) a particular borderline ‘cancerous’ (to use a name, or metaplastic , or etc etc … if you prefer) tissue appearance. Similarly a physical quantity could be given different names in physics – a proportion such as 30% more blacks than whites or 70% less whites than blacks, can have very different social meanings, terms and their bias. You don’t have to believe in the thing world to feel differentially subordinated by the differentiating powers of different terms and contexts. This reminds me of Frege’s error, could go back to Pecheux to review this? Also re check difference between Bachelard and Kuhn in Le Court’s book.

‘An alleged statement of the reality of the system of entities is a pseudo-statement without cognitive content. To be sure, we have to face at this point an important question; but it is a practical, not a theoretical question; it is the question of whether or not to accept the new linguistic forms.[1] The acceptance cannot be judged as being either true or false because it is not an assertion. It can only be judged as being more or less expedient, fruitful, conducive to the aim for which the language is intended. Judgments of this kind supply the motivation for the decision of accepting or rejecting the kind of entities.’ (Carnap)

Here, we have language used with intention, motivation, which begs the question, not of the belief in the eternal thing world, realism, but a tacit acceptance that decisions about whether to accept the naming of things may depend upon egoist interests in (economic perhaps) interest and therefore be political, a tool of a particular governmentality and market. The speaker uses the new entities, the pure empiricist may take a higher ground and argue this in no way implies belief in the reality of the new entity, but the market will sell the new entity as if it is real, and consumers will demand it with their own mentalities shaped by the market’s use of language. This is where Evidence IS ideology. To deconstruct the power effects of the language of EBM is not necessarily to hold a belief in the thing world, but is based upon acceptance of language effects of power-resistance and motivation, egoist and collective interests, agendas and non-agendas, and therefore subordination and possible exploitation of the weak. The acceptance of the abstract entity ‘borderline pathology’ implies acceptance for the abstract entity ‘normality’ may not imply a belief in it, but a decision as to its (motivated) utility for the speaker. The acceptance opens the door to infinite overdiagnosis and hinders restraint of overdiagnosis. This isn’t to say that logical positivism and empiricism as applied to medicine doesn’t have a use where current illness or current undetected actual clear illness is concerned, but in the latter case there us always a problematic border the description of which is an ideological event.

[1] my italics, this might be a new diagnostic test result, a level of combinations of SNPs, a genetic fingerprint test, for example

Human Sexuation is that which makes sex sexy for us, it is constituted at the interaction between nature and culture; the bottom two cells of the quadrant of Lacan’s four ( five if you include the market case) structures of discourse. These cells hold the Truth of discourse and the product of discourse. Here the truth is/becomes feminised or masculinised in its encounter and always misrecognition by the product of EBM.  In the discourse of the market under capitalism, EBM works to provide one of the products, bodily pathologised representations, for the market. The ‘truth’ of EBM is its misrecognition of this product because of the impossibility it exceeds. The truth, that may be Profit, Surplus Flesh, Surplus Life, is the misrecognition of the perception, the recognition of a ‘made to appear’ and therefore ‘evidential’ pathologised flesh, as the point of contact between nature and culture, the aporia of biological normality, an impossible yet demanded Real. The misrecognition provokes crisis – for EBM, which has to work even harder, to produce more flesh, more market penetration. So one of the ‘core values’ of EBM, that is ignored or misrecognised by the governmental practice of EBM, is market penetration. It is this that sets the limits for EBM. The diagnostic cut-offs, the test parameters set by the market to define the pathological, that determines success or failure. Success for the market demands a maximisation of market penetration and Profit and therefore of pathology.  The sexiness in the discourse of the market is of a perverse sadomasochism, the Other is still performed for, but is disavowed so that the human is thoroughly tortured as an object of bodily parts technically, but also because as human provides a jouissance through imagined suffering by the torturer, which could also be an autoerotic manifestation of self-consumption and torture.

Put simply, EBM misrecognises the products of its diagnostic processes, i.e. ‘pathology’ which warrants the existence of an impossible normal. This provokes crisis when the cut-offs applied to tests (eg low risk versus high risk) break EBM’s internal rules about the limit, and fails to maximise pathology and minimise the non-pathological. The crisis provokes more and more medicalisation and overdiagnosis.

What is the ‘Evidence’ of ‘Evidence Based Medicine’ anyway? This short essay situates a critique of ‘The Philosophy of Evidence Based Medicine’ by Howick J (2010)  within continental post structuralism and Western pragmatism.

Howick wrote a book called ‘The Philosophy of Evidence Based Medicine’ in 2010 that is now the basis of a course being run at the Oxford Centre for Evidence Based Medicine, it is a detailed explication of the finer points and conundrums of the logical positivist industry of ‘evidence’ production – the research that tells us whether treatments work or not. Below I suggest that it is naive and perpetuates the harms disseminating from the real-EBM brand, EBM(TM).

Howick’s claim is that of a discourse of the University. It produces ‘subjects-of-science’ who ‘obey orders’ in discourses: the patient as the fuel of the consultation, the engine room driving sales that is the market, the governmental headquarters that is the University and its positivist experts. It is hanging on to the belief that EBM’s evidence is ‘only’ and ‘solely’ what is useful. The Frankfurt school critiqued positivist methodologies, that elevate rational mathematical logic to the status of guarantors of the only truth to be considered, and found it to be reifying (de-humanising, the banality of evil) and creates a psychopathic neosubjectivity. These are features that Horkheimer et al claimed made events like the Holocaust possible. Marketised EBM evidence has resulted in many deaths already. It is well nigh time for the medical community to take a much more sceptical view of EBM-TM and to embrace a more sophisticated media literate analysis of its praxis. The dominance of EBM must be challenged to support a movement to de-medicalise precisely by striving to minimise destruction of the material world by de-industrialising and radically changing our global capitalist political economy.

Pragmatism challenges Howick’s positivist implication that the logics and evidence of EBM should be the sole grounds for believing whether a treatment works. Pragmatism is a major philosophical field. The word is used somewhat differently from its every day use implying sufficient reason for action on practical grounds. It seems to be very close but not the same as a continental post-structuralist philosophy based on Marx/Althusser/Foucault/Lacan: the main difference being the latter’s emphasis on discourse constructing the objects of which it speaks and subjectivity being both a misrecognising desiring/demanding barred subject through and in language and the product of the ensemble of social relations, in dispositifs of power and resistance, domination and subjectivation – in other words a ‘political economy’ socially positioning subjects based on false logics through enterprises and discourses. Such dispositifs include the Evidence Based Medicine brand or movement.

Howick in his book ignores these major western and continental philosophical developments from Marx’s dialectical historical materialism (which rejects both Feuerbach’s crude emprical realism and Hegel’s German idealism) to Dewey’s pragmatism. Pragmatism has been ignored by Howick in his claim that ‘evidence’ is

defined simply as ‘grounds for belief’

whilst truth for pragmatism would claim that an assertion that predicates truth has a property called truth only if the claim is useful to believe. I claim that for EBM its marketised EBM (TM) is totalitarian and becoming increasingly less than useful, even harmful to believe. This is because it is firstly, misleading empirically through market bias (even editors of the Lancet and NEJM claim most research published is even empirically false let alone biased see citations in Williams post on medialens’ website), as well as secondly, epistemologically overblown and naive about the status of its ‘knowledge’. By claiming that its logical positivist ‘evidence’  must be the sole arbiter of ‘treatment effectiveness’ it is in denial of the social construction of the human subject and as a result has become a mere slave to the market’s Master. Howick’s views are based on a Cartesian philosophy that gives thought an original divine primacy, ‘pragmatism’on the other hand would argue thought is the product of organism and environment, not an originary product, or an original ‘given’ for man.

Howick presents the realism of empiricism, (a view of experience as corresponding exactly with a reality out there) in opposition to idealism (mechanistic reasoning) but ignores the possibility of neither being useful, or true, possibilities held by Marx’s dialectical materialism that moves towards a scientific pragmatism that was to come after Marx (see article by Sidney Hook), in which a human nature, as the abstractions produced by our thoughts, changes and emerges as needs must in different historical conjunctures over time.

Pragmatism thinks of epistemology (what can be known) from a coherentist viewpoint rather than correspondence, but rejects a realism philosophy that claims sensationalist (ie through perception through the senses) knowledge represents the reality out there.

So, what is the ‘evidence’ of Evidence Based Medicine’?

‘Evidence’ Latin: ‘e’ ‘ videre’ : ‘what is given out to be seen’ – so rather than being defined as Howick would have it as ‘grounds for belief’ I think this could and should be better defined as what is made (manufactured) to appear; and after Foucault and Lacan, evidence is what is made (constructed) to appear (as ‘superficial appearance’) as the objects made by discourse, precisely what is not superficially self-evident, also always functioning within structures of discourse within dispositifs and their political economies on a (de)-or not de-barred subject, of fantasy and need/desire.

The harms of a marketised EBM(tm) are compounded by the internally set limits that prevents EBM from confronting the aporia the sheer lack of knowing that much testing skirts around, this manifests itself in the mystique and perhaps fetishism of a test’s cut-offs, the point at which pathology is discursively created. The lack of meaning at the heart of screening tests, tests that have uncertainty associated with predicted outcomes (what I have called diachronic predictive tests) is what undermines the applicability of EBM(tm)’s positivistic mathematical probabilistic logic.

The abstractions of thought, the very formations of our ideas, our humanity, what it means to be human, changes as our experiences and needs change with time, historically. This is historical materialism, a rejection and new synthesis of crude realist empiricism and German idealism giving primacy to thought. The subject-object opposition is rejected and becomes a subject-truth opposition. This is what EBM is failing to embrace.

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

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

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

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

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

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

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

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

“Biological normality is an unenframeable and enframing social construct and a discursive practice that by being both mandatory and impossible engenders a crisis for the subject and categories of pathological tissue or madness or amorality that can be infinitely expanded and, as ‘flesh’, incessantly sacrificed and consumed as the hyper-precarious in debt ‘patient’ and ‘medical expert’ enjoy a consummation in the perverse sado-masochist torture chamber of unfettered capitalism.”

Owen Dempsey 2015

Just as geneticists no longer think of a gene as a ‘thing’ that determines traits but regards genomics as a much more complex process, in a similar way I think we should think of diagnosis not as an end in itself but as a process.  This is a ‘process ontology’, (of the kind explored by continental philosphers such as  Heidegger, Deleuze and Badiou), such that the process itself leads to new ways of Being. For geneticists epigenesis refers to the way the environment, including environmental changes due to behaviours, can intertact with the genome to influence our natures. For example studies suggest that smoking in adolescence may lead to an increased likelihood of obesity in the adolescent’s grandchildren. So too for diagnosis the process of diagnosis results in a new way of Being. In a way Marx’s historical materialism which suggests human abstractions and thought change over time in response to changes in social and economic environments is also a form of process ontology.

This is a challenge to the traditional notion of a diagnostic test, as exemplified by the Oxford Handbook of Clinical Diagnosis, which portrays a diagnosis as something you may have or are unlikely to have, something a ‘diagnostic test’ determines. This traditional notion  sees the result of a screening test as ‘more of a presenting complaint’.  This is harmful because it prevents us seeing the screening test as part of a very important diagnostic process.  I think it is better to characterise all medical investigations as part of a diagnostic process and this includes elements of history taking and examination and even therapies.

What they all have in common is a differentiation of the subject between two or more different potentialities, “you probably will get ill, you probably won’t”, “you probably did have cystitis or you probably didn’t”, “you probably are anaemic or you probably aren’t” , “you probably should have a biopsy or you probably shouldn’t” – hence the name: dia-gnosis = ‘to know between’.  It is of course possible to conceptualise, develop and use tests to achieve particular diagnostic functions, to achieve more or less certainty about the presence or absence of a present or future pathology or benefit or harms from further diagnosing.

The screeningtest performed by default, invitation or request for a ‘condition’ in an individual who does not have symptoms of that condition is also a medical test, and therefore part of a diagnostic process. It determines a difference between tissue or organism potentials. The screening medical test is of particular interest because it operates at the borderline, and exploring this borderline reveals some of the dynamics influencing the process ontology of overdiagnosis.  (Where overdiagnosis is the result of medical testing that reveals a positive pathological potential that is exaggerated, wrong, false, and  misleading and leads to further diagnostic processes of one sort or another.)

We ‘think’ the borderline representations of tissues or tissue biometrics from screening tests of diagnosis as the abstract ‘form’ of thought that is ‘pathology’ or the way we think about and value and imagine ‘pathology’ – an abstraction that by the nature of this abstract ‘form’ necessitates something that is ‘not-pathology’ and this is the impossible fantasy of a risk-free subject, also referred to as the ‘normal’.  It is this borderline between an abstraction pathology and its imaginary demanded and impossible opposition ‘normal’ that is dynamic and shifts in response to advances in technology, always at the limit, posing unanswerable questions that demand to be answered.

As technology advances and new tissue representations and biometrics are produced such as genetic fingerprinting to predict cancer risk, so the nature of our subjectivity changes, as we are made more biologically insecure by being ‘securitized’ by diagnosis.  This is a process ontology, an anthropological mutation that is creating a new way of Being for humans. The process is compounded and accelerated  by three aspects of another process:  neoliberalism in times of ‘austerity’, which: a) marketizes diagnostic processes for profit b) demands individual self-surveillance creating more biological insecurity and a subject-of-precarity and c) uses the rhetoric of austerity, debt and benefits to threaten and bribe to exclude marginal groups and enforce compliance with state or market diagnostic processes.

As well as market and bio-political processes to enforce secure citizenship, entitlement to benefits and temporary hoped for reassurance, diagnostic processes (such as the MammaPrint genetic fingerprinting test to estimate risk of recurrence after treatment for early breast cancer) involve a trade off between those that shall be spared unnecessary further diagnostic processes (eg not receiving chemotherapy after breast cancerbecause it won’t help) ) and those that may be excluded from receiving beneficial diagnostic processes (ie not receving chemotherapy after breast cancer when it would help).  At a population level some are spared at the expense of the  neglect of others. This requires a valuation of a cut-off point that is influenced by opposing pressures such as the need to penetrate the market by demonstrating cost savings, or to appeal to manufacturers of chemotherapy by maximising treatment levels , or to reassure doctors/patients averse to over treatments, or to reassure doctors/patients averse to undertreatments. These influences can account for the way diagnostic processes are researched and reported. The health insurers monitor claims for molecular diagnostics because of ‘indication creep’:the increasing use of tests outside of approved guidleine criteria suggesting that healthcare costs will increase even if a test is marketed in terms of reducing costs.

On a pessimistic note, surprise surprise, with the a) Transatlantic Trade and Investment Partnership (TTIP), b) the dismantling of the UK NHS under an ever more neoliberal state institution, and c) the hunger for the markets to form partnerships between medical managers of doctors, medical intelligence suppliers, therapy and diagnostic distributors, health insurance provison and coverage criteria, and medical diagnostic and therapy manufacturers (also known as theranostics and personalised  medicine)  – we are seeing, in the UK at least and probably globally,  the tail of unfettered capitalism wagging the tail of the overdiagnosis doggie.

An account of Derrida’s and Johnson’s deconstruction and the concept of the frame in relation to modern medicine and the logic of normality: 

In The Purveyor of Truth – a collection of writings, Derrdia critiques Lacan’s seminar on The Purloined Letter by Edgar Allan Poe. And Johnson critiques them both. Literature is described, and analysis of literature deconstructed. The description of ‘writing’ problematises the interpretation of writing, examines the potential multiplicity of significations that disseminate from writing, and concludes that to describe mandates an enframing that is paradoxically also impossible. I describe the way a signifier ‘normal’ functions in society and medicine using these ideas. 

Biological normality is an enframing social construct and a discursive practice that by being both mandatory and impossible enables powers to create categories of pathological tissue or madness or amorality that can be infinitely expanded and incessantly sacrificed and consumed as the hyper-precarious patient comes into contact with the jouissance of the medical expert in the perverse sado-masochist torture chamber of unfettered capitalism.

Cells multiply through the replication of DNA, a very lot of times all the time, and occasionally the reproduction goes wrong, and mutation occurs and dis-ease results. Why would it go wrong? Research suggests it seems to go wrong at a rate proportional to the rate of multiplication, and this accounts for two thirds of cancers, random errors in the DNA replication process. Any repetitive transcription of information may be prone to random error, I guess, but to say this isn’t to explain why. Nonetheless, this evident error proneness explains some dis-ease and even underpins the ageing process and death. I won’t say normal ageing process, because ‘normal’ isn’t the same as natural and is anything unnatural anyway? 

NORMALITY is an unanswerable aporia – a Kantian antinomy, but this doesn’t stop it functioning like a powerful  signifier with concrete material effects. The normal-pathological opposition is a duality that does not represent two independent wholes, instead a third term is created, a remainder, an inbetween-ness. Is this the failure of the Hegelian dialectical synthesis, instead both simultaneously normal and pathological and neither? Given the negative entropy of the universe what can normality mean? If we cannot define normality, can we define health, or healthy in terms of tissue representations? Something might be said to ‘look healthy’ which might say more about the limits of seeing, than about the nature of the tissue. If we cannot define healthy tissue in terms of appearance this implies we can never be sure if the said tissue which ‘looks healthy’ is unhealthy or pathological. Therefore population screening of asymptomatic tissue will always yield anxiety provoking borderline uninterpretable appearances and at the borderline there will be a naming-fest. (as exemplified by the numerous names given to borderline tissue representations in breast cancer screening)

It can be predicted that in an age of precarity and the sado-masochistic torture chamber of capitalism that human capital will be consumed at an ever faster rate, disseminating more selfish monistic (h)self-flesh to be consumed even as it is itself being consumed by itself.

Normality is a human construct like space and time, so there is perhaps a logic of normality, that might be thought of as just as paradoxical as Derrida’s framing (as described in The Purveyor of Truth in relation to writing and literature), whereby as noted in Johnson’s chapter in the same text, normality as a framing  is mandatory and impossible at the same time. I am applying these ideas of deconstruction here to a biological social field or a field of bio-politics. Is such an application also enframing?

Be Normal! is the injunction of Modern Healthcare as previously noted, the injunction mandated by e.g. the UK policy to have a national population based breast cancer screening programme. Be Normal! may be the injunction mandated by the sanctions threatened for those obese, alcoholic and Heroin addicted people who fail to attend ‘treatment’ programmes, or for the parents who do not have their children vaccinated.

Normality requires a definable identifiable objective – it could be said that we’re all normal all the time no matter what, but this is saying no more than we exist as Beings, not very helpful. The logic of normality for medicine is part of the logic of seeing, and what we experience (by seeing) of the ‘is’ of ‘what is” is different from ‘what-is’ by precisely what we see, this is Heidegger’s ontological difference.

Foucault might argue that ‘ Biological Normality’, historically is a social construct that enables Power to be exercised over those that threaten Power by enabling them to be defined against a norm e.g. as ‘indecent’ or ‘amoral’ or ‘high-risk’. Vague generalisations that can be applied by the powerful to all, at will, maintaining and reproducing the power of the already powerful. Canguilhem, one of Foucault’s teachers argued that Error is the mark of Life, but this may also be to enframe Life as ‘random error’, enframing the unframeable.

The perversion and accelerating self consumption and production of flesh by capitalism requires an ever decreasing threshold for pathological dia-gnosis, even to the point of pre-empting the diagnosis of current ‘pathological’ tissue through crystal ball future-telling genetic predictive screening creating pre-vivors. Even without genetic screening however, the threshold is being driven downwards downwards.

Illness, like child sexual abuse, demands detection/help/treatment/prevention to ease suffering and exploitation. The naming process demands an opposition between normal childhood experiences and non-illness, these in turn lead to unenframeable potential demonisation of the ‘abnormal’ : a vague and moveable/expandable human-catchment, the size of the fishing nets expands as the powers that be, always feeling threatened, demand more control over the lives of the population.

Heroin Assisted Treatment (HAT)

HAT is ‘Heroin Assisted Treatment’, setting up supervised clinics where addicts can self inject Heroin that is prescribed. A recent BMJ article (ref 1) explains the evidence in favour of this ‘treatment’ benefiting those that have been ‘refractory’ to help with oral substitutes such as Methadone and accompanying psycho-social supports (e.g. Counselling for anxiety, stress, PTSD; and help with housing, debt management; and access to group work with people who have overcome a substance addiction – called Mutual Aid).

Implementation of HAT will be politically unacceptable under Capitalism

This account explores the problems of implementing such treatments within the culture of capitalism and a neoliberal de-regulated free market where ‘anything goes’. From a psychoanalytic perspective such de-regulation has caused a structure of the social-economy to emerge that is one of perversion, where the individual is now de-humanised ‘human capital’ that self consumes through consuming objects ”of pleasure’. (Ref 2)  Such objects include the ‘medical test or treatment’. The administrators of such a culture – governing or sham-governing act like sadistic torturers – cycling between a) promising relief and b) blackmailing with pain. These elements are applied to the problem of HAT and its implementation.

Implementation is unlikely in a failed market based healthcare system.

Whilst the trial evidence in terms of societal costs and health benefits seems fairly solid in favour of Heroin Assisted Treatments for the ‘refractory and suffering addict’ the possibility of implementation faces a huge political barrier. The influential think tank ‘The Centre for Social Justice’ headed up by government minister Ian Duncan-Smith published ‘No Quick Fix’ in 2013 – this prepared the ground for Conservative policies to impose benefit sanctions on addicts (Heroin, Alcohol, even the Obese) who ‘refuse’ to access treatment. The report likens Methadone to providing vodka to an alcoholic instead of his preferred gin and tonic, and suggests sanctions and withdrawal of Methadone may, through the break up of families, homelessness and emotional breakdown, actually encourage engagement with treatment and ultimately, abstinence.

“Much of the system’s response to addiction remains to supply methadone to heroin addicts, a policy akin to supplying an alcoholic with vodka in place of his preferred gin. Methadone is an opioid (artificial opiate) invented in Germany which mimics some of the effects of heroin but without the ‘highs’. However, many abuse it, with some addicts selling their prescription to other addicts. It is a legal class A drug supplied to addicts through the public purse.” (p27)

“The CSJ has heard, however, that current reforms to the welfare system may be drawing a previously hard-to-reach group of addicts into treatment. For some addicts, a ‘nudge’ is required before they seek treatment. This can be the negative effects upon their own health, getting arrested, or the prospect of losing their children. The CSJ has also heard that for some who had refused treatment before, reforms to the welfare system under the current Government have led them to come forward for help with their addiction.” (p53)

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

This rhetoric of ‘abstinence’ or refusal of treatment is filtering into clinical work as substance use services are competing for tenders and cutting costs drastically.  The likelihood of implementation of Heroin Assisted Treatment seems light years away.

The political move to the right and repressive attitudes to addicts is fuelled by the financial crisis and austerity. The market economic system has failed and leads to health inequalities.  The addict is just one example of a subject compulsively ‘enjoyed’ by a market system based upon a discourse of self-sacrifice and the always failing satisfaction of chasing profit for profit’s sake. There is no longer any pretence of achieving social security for all.  The chances of HAT being implemented may require a revolution in our political- economic system first.

Childhood Vaccinations in Australia

Another example of bio-politics in action is the recent announcement that the Australian government is planning to withhold welfare payments from families that do not have their children vaccinated.

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

The prime minister said that his government was “extremely concerned” about the risks posed to the rest of the population by families who chose not to immunise their children.
“The choice… is not supported by public policy or medical research nor should such action be supported by taxpayers in the form of child care payments,” Mr Abbott said in a joint statement with Social Services Minister Scott Morrison.

Again we have a ‘threat’ demonising a section of the population, ‘people who choose not to vaccinate their children’,  and a sanction to protect ‘the taxpayer’. This is a bio-political act as with the intended plan in the UK to sanction addicts who fail to complete or access ‘treatments’ (and become abstinent).  People are positioned as those who ‘must’ comply. A condition for being valued as a citizen opens you to blackmail, and this is justified in terms of the vague universal ‘threat’ you may pose, and in times of imposed austerity is framed as being especially justifiable in terms of being fair to the ‘taxpayer’.  A parent’s  choice for their child is now being managed by the state and The Law. Does the State feel free to do this because it is no longer restrained  –  the permanent crisis of capitalism, with the resultant evaporation of any prohibitions on State actions, leads to a need or drive for the state to ‘enjoy’ its citizens through mechanisms of promised ‘protection’ alongside sadistic punishments in the name of ‘necessary austerity. This becomes medical fascism.

It is possible to argue that medical interventions ….. are part of a structure like a see-saw – and always susceptible to the drives of a capitalist system that is always in crisis and is currently reacting to the 2008 financial crash with a rhetoric of austerity. See sawing between a rhetoric of credit and debt. Two opposing activities are taking place concurrently : and both act upon this object’s ‘access to medical investigations and treatment’: the drive is structured like a Lacanian structure of perversion wherein the subject has become ‘free’ as the master has evaporated into thin air, as the failure of capitalism has become apparent – especially given the Troika’s intransigence in relation to Greece’s permanent indebtedness.  Thus access to medical investigations and treatment has become the object of enjoyment for its own sake, any ‘test’ will do. The pleasure (beyond that which will provide for physical survival) is the jouissance obtainable through providing the other with access to (and controlling) their access to jouissance. Thus, as with the sadist, of perversion, the subject the medical-technician has the Other, the ‘patient embodying the flesh to be tested, treated, (and sacrificed) has the patient at the mercy of his whims – jouissance is obtainable  (for the medical-technician) by offering access to medical care: suggestive of a) offering ‘prevention of pain’,  even at the same time as b) blackmailing the patient as a way of limiting access and causing pain.

This is line with the perverse structure of capitalism where ‘anything’ can be interchangeably needed enjoyed and used for the ‘flesh’ or ‘flash’ of jouissance it provides but nothing is desired for its own sake, for the promise of its desire for the subject. A horrible example might be the man ‘with everything’ who no longer desires love through the love of the other, but instead transgresses, and having lost his master and castration, is now driven by the need to ‘use’ or ‘enjoy’ prostitutes, or voyeurism or sadism and so on.

PERVERSE TRANSGRESSORS

It is imaginable that such a man – too close to the object of enjoyment – becomes so free of any law that he makes his own law, as a banker selling high risk debts to the vulnerable, a pharmaceutical dealer hiding unfavourable trial results, or even a surgeon such as Ian Paterson assaulting healthy women with unnecessary breast excisions and perfecting inadequate excisions on women with breast cancer.

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

Drug users should be able to get heroin from the health system

1. Martin T Schechter, professor, School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, Canada

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

2. Lacan and Debt, by Andrea Mura

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