Interesting post from Eyal; provokes thoughts about when language reveals ‘white privilege’, racism, and the impossibility of ever being in the ‘other’s ‘ shoes (perhaps the impossibility of the sexual relationship too, obliquely anyway).

 

Truth from Eretz Yisrael

I love Tamer Nafar. What an excellent performer! I love his music and his politics. Never spearing his audience the burden of politics, and the multilayered difficulty of being a Palestinian, combining criticism of the West and Israel, with that of Palestinian society, and of those observing it. I thoroughly enjoyed his show last week, which was part of his UK tour, where he tried new electronic material, this time in English. It was a huge hit, if you ask me. Very different to his previous works, and really taking his art to the next level, upping the game and giving the audience an extraordinary time.(*)

But what was particularly evident for me in comparison to previous DAM songs, is that it really expressed more forcefully how tired he is of it all, and how he just wants to live his life and be happy. Aren’t we all!? The best…

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Amnesty International have called for an arms embargo on Israel (as well as on armed Palestinian groups). In other words, for example, the U.K. (and the USA etc.) should stop selling arms to Israel.

This is because of the irrefutable video evidence that Israeli snipers are deliberately killing unarmed protesters in Gaza.

The protesters are Arab/Palestinian refugees enclosed in a strip of land on the western, mediterranean coast of what is now called Israel. They were put there, or driven there, in the late 1940s early 50s after Zionist militia massacred many Palestinians in order to take their land – a disaster called the Nakba.

The protesters are protesting their right to return to the villages of their origin as they are entitled to do under International law – having fled conflict – and being now displaced from what is rightfully, legally, theirs, their homes.

[on the 11th of December, 1948, the UN General Assembly resolution 194 recognized the right of return of Palestinian refugees, and this resolution, seventeen years later, has been reaffirmed more than a hundred times since, and more than any other resolution in UN history.]

Many UK politicians turn a blind eye to these murders saying Israel is our ‘friend’ and a ‘democracy’ – this is sheer hypocrisy. Motivated by a thirst for power and domination of the Middle East.

Just imagine if Assad, or Kim Jong Un, or the Chinese were doing this. The outrage would be in the headlines of the mainstream media.

What can we do? Perhaps consider writing to your MP https://www.theyworkforyou.com – ask them what they are doing about this.

The question arises because some efforts to challenge US/Fr/UK interventionism in Syria – the apparent desire to depose Assad, (as Sadam Hussein was in Iraq) – is challenged by critiquing media that characterise Assad as a monster. But this may be received as if Assad is a benign democratic authority. I would argue that challenging imperialist intervention in Syria can take place alongside awareness that there is resistance within Syria’s own population, from socialist and non Jihadi forces or efforts, to an oppressive Assad State machine.

And, that it is reasonable to try to support their resistance against oppression by the Assad state machine without meaning you support either imperialist intervention or the efforts of Jihadi extremists (some of whom may be Syrian in origin).

See interview with Yassin Al-Haj Saleh, a Syrian communist imprisoned by Assad’s state for 16?yrs: In Syria, The Left and The World. See here. A source from a refugee now outside Syria – true – but a voice that has, it would seem, experienced Assad’s oppression first hand.

Though supporting socialist efforts like this may mean identifying the oppressive nature of Assad’s state machine. Which, in turn, may lend succour to imperialist propaganda.

It seems wrong to silence criticism of Assad on the grounds that this support imperialist efforts. To do this would be to be complicit with his oppression of political resistance within Syria.

After all it is also possible that Russia’s support of Assad’s apparently legitimate authority in Syria is a kind of neo-colonialism in the name of humanitarian protection of ‘a minority’ (in this case Syria itself). Which would be a kind of reversal of the excuse behind Imperialist colonisation and its apparent humanitarian interventions.

However it is possible that some remain silent on Assad’s oppression as a tactic aimed at resisting US/Fr/U.K. intervention – but this tactic may misfire as it also tends to support pro Assad voices and pro Putin voices.

An example:

Take the sentence:

“Early diagnosis of cancer by population based screening prevents cancer deaths and is a good thing.”

This summarises the concept underlying, say, the UK national breast cancer screening programme (UKNHSBCSP).

It is an example of the concept of anticipatory care in general where :

“Predictive risk measurement and diagnosis by population based anticipatory care programmes prevents premature death and is a good thing.”

What is at stake here is “a good thing”.

The question is: “What determines whether the concept should be marketed, commissioned or translated into state policy, as so-called evidence based healthcare, as, that is, a good thing ?”

For pragmatism (P) ‘a good thing’ is a practical thing, where the term practical, as used here, specifically means that the specific form of anticipatory care achieves the active intent of the programme, here defined as preventing specific forms of (premature) death.

By contrast, for Logical Empiricism (LE), the question posed of a good thing depends upon an evaluation of all of the possible conceivable and observable effects of the programme.

So, for example, LE would take into account and value as meaningful, as many empirical observations of harms as possible, such as the impacts on health of for example, mastectomy as such, of side effects and complications, and of longer term but still conceivable, observable, sequelae (such as radiation induced cancer and heart disease).

For LE the so-called observation-sentences (for example, “mastectomy can lead to wound infections and chronic pain”) that attest to the predicate “a good thing” must refer to observable empirical outcomes that make sense, have empirical meaning, and are therefore sensuous, imaginable or conceivable at an individual level.

Therefore, overdiagnosis (OD) is not a meaningful outcome for LE because, most simply put, it is not sensually experienced.

This is a dilemma for scientists who ‘feel’ OD is important but are unable, under the precepts of LE, the basis of Evidence Based Healthcare (EBHC), to make it count as value-able in the inquiry into, say, breast cancer screening.

As an aside, the term premature functions here as an imperative term for the subject. It signifies the subject for another signifier thus: “You not only can but should, even must, try to prevent your premature death, because your proper mature death lies further in the future, some time, not defineable.”

LE accepts the existence and importance of causes and mechanisms of ill health production, such as, say, radiation inducing cancers, because these help to identify possible conceivable, observable, outcomes, which will therefore influence methodology and study design. For P, these causes and mechanisms do not exist, or are meaningless, because the focus is on the relevance of outcomes to the active intent of the programme of anticipatory care and not the wider evaluation of what might be, or attest to, a “good thing”.

In the evaluation of the UKNHSBCSP we can see the workings of a subjective pragmaticist empiricism, that trumps LE in general.

So, that a statement by a cancer expert in 2012 , by Prof. David Cameron, who was on the UK’s independent review panel for the UKNHSBCSP:

“I personally would prefer to avoid a breast cancer death … and the risk that I might have a cancer over diagnosed and therefore treated is one I would be prepared to take”

effectively privileges the active intent of the programme at the expense of other harms that may, if counted and valued as harm as such, negate the conclusion that screening is a “good thing”.

This privileging of the active intent of an intervention devalues harms as such and leads to ever expanding, intensifying forms of anticipatory care and overdiagnosis. It also privileges the intent, scientific interests and healthcare goals of particular clinical specialisms. Cancer specialists tend to be pragmaticist, and therefore interventionist, with respect to their own cancer research and interventions.

Overdiagnosis is an anomaly, meaningless for P, and a contradiction for LE.For P it is meaningless because it is not relevant to the active intent of anticipatory care. For LE, it may be conceivable and measurable at a population level but it is not observable. To be observable is to be experienceable at an individual level. And although it is (indirectly) deduced and measured by LE as a logical (positivist) population outcome – OD is not empirical, it is purely positivist. Thus, OD is, in theory, finite and determinate, and measureable, but it is not imaginable, experienceable, or, literally, sensible.

LE is an ally for social democracy under capitalism because it attempts to value all possible conceivable and observable outcomes that attest to a good thing. It is more likely to objectively strike a more equal, just balance between the harms and benefits of forms of healthcare.

Conversely, P is an ally of neoliberalism under capitalism. Capitalism needs competition and innovation and monetised growth to survive. Because P ignores harms not relevant to the active intent it privileges intervention, and therefore promotes neoliberalism’s necessary endless innovation and the marketisation of ‘new’ products as a good thing.

Therefore, LE has more potential to limit harms due to anticipatory care whereas P continually intensifies harms due to anticipatory care.

The social democratic LE scientists would like to value OD, as harm as such in determining a good thing, for the sake of collective justice, but are unable to make it count as value-able for themselves, and even less so for the neoliberal pragmaticists who are only swayed by active intent, that is, for example, by saving lives from breast cancer deaths.

In the anticipatory mode of care overdiagnosis is an inevitability, but, at the same time it is personally unimaginable, and so compelling citizens to decide whether to comply with screening invitations, as if this is a ‘fully informed’ and ‘fair’process, is anti-democratic.

The cause of this situation is the belief that it is possible to scientifically define the precise biological boundary between normal and pathological forms of life in order to predict future disease. But, because life itself functions alongside and through error: environmental contingencies, constant mutations and non-linear responses – it is inherently unpredictable. To claim, for example, that a screen diagnosed cancer is always ‘real cancer’ when only 1 in 3 of them would have caused harm in the future, is to deny life’s mystery, this unpredictability.

Because of the unpredictability pre-emptive attempts to treat on the basis of anticipation will always over treat, and this will always result in non-empirical, non-sensible, unimaginable, non experienced, overdiagnosis at an individual level. And therefore anticipatory modes of care will always be unjust and anti democratic. It will make the citizen increasingly vulnerable to being positioned as limitless clinical labour for a neoliberalised monetised market, warranted not by a social democratic objective logical empiricism but by an interest driven neoliberal subjective pragmaticist empiricism.

Individual becomes Masse

Value Religion Racism Price Neoliberalism and consciousness.

We should be worrying about questions of value where value is absolutely distinct from price.

This is because neoliberalism both embellishes some values whilst hiding others behind a screen. It fools us, makes us feel aware even while we only have an imaginary relation to our real existing conditions, value is hidden, and values are manipulated behind an apparent democratisation of decision making based on price, numbers, and in the name of rational choice. The felt value and the stated price are two very different things.

To fight the deception and destructive effects of this we must realise that values can only be felt by us and shape us as if true if they are effects of conceivable practical consequences for the individual (to paraphrase Pierce).

If we can’t conceive it or imagine it it can’t be true.

Neoliberalism is a mask for the obfuscation of felt values, and is a filter that drains human value, and life, and agency, and retains only the compliant automaton, who ‘stupidly’, dehumanised, tries to calculate his or her way through decisions – not knowing how the dice have been loaded, how the individuals health is being stolen for the market. Individual become Masse – raw material, under a totalitarian ideological pragmatic philosophy of pure selfishness. Where the measure of truth is personal satisfaction and personal prejudice at the expense of the ‘totality of facts’.

Supporting Israel, is supporting a totalitarian neoliberal ideology of selfishness, identical to the ones we face ‘back home’ – in the U.K., Canada, USA, etc.

As Kurt Tucholsky put it, who in 1933 warned against totalitarianism under Hitler, whose un-German books were burned, and who probably committed suicide in 1935: “A country is not just what it does, it is also what it tolerates.”

And it was surely ironic to read these words in the Holocaust museum in Jerusalem yesterday August 2017. Where even the holocaust becomes a propaganda tool spreading fear amongst Israeli Jews in order to support Zionism and a Jewish, ethnocentric and inevitably racist apartheid state.
The Jews in Israel face exactly the same problem we face in the U.K. and the USA. The congregation in the liberal re-constructionist synagogue in Jerusalem, with their songs, fellowship, face the same problem. But, does religion offer a kind of seductive but false ‘hope’ that after the darkness God will fix things in the end? The talk of God, as Opioid, Tylenol for the masses. How do we resist the power of the neoliberal elite most effectively today. Israel is surely one of neoliberalism’ weakest spots because here the contradictions of neoliberalism, the brutal oppression of millions of Palestinians through colonisation, are most visible. What is the most effective response? Organise? Educate? Write? Publish?
Religion might offer the most personally satisfactory solution to life’s inherent paradoxes but that does not make it true. Even just as the arch pragmatist the American William James persuaded young minds to believe in God, using neoliberal arguments, his economised religious pragmatic form of belief devalues our own consciousness and increases our vulnerability to becoming disciples of false Gods, Gods of racism.

Care is required because the EBM methodology and rationale reinforces the maximalist mindset

It is natural and makes sense to want to improve medical practice.  And it seems to make perfect sense to want to intensify the application of the scientific method and EBM methodology to the problem of misdiagnosis. However, isn’t the sheer rationality of this quite scary, quite inhuman, as if beyond care?

 

This positivist EBM methodology has the same rationale that has led us from Halstead’s mastectomies, to national breast cancer screening programmes to Oncotype DX.   And it is this EBM methodology and rationale that produces more interventions for the market.   This reinforces the maximalist mindset that functions for capitalism to increase the economic productivity of life itself.  But what is the aim of this EBM rationale today? Is EBM derived innovation aimed at reducing levels of iatrogenic harms already in existence, a damage limitation exercise, or to provide care that is harmless, or to make us live longer?

 

Remember that the policies of national screening, early referral, and predictive diagnostic interventions are aimed at prolonging, or to use the rhetoric, saving, life. They are the biggest cause of misdiagnosis and harm and, like austerity, are a matter of politicised choice. This preventive medicine is imposed upon the well.  This kind of care goes beyond care.  It is not the imperative, must do, kind of care for the present day suffering of the already unwell.

 

There are ways to use EBM to reduce iatrogenic harm and improve care.

 

Firstly, would be to actively identify and disinvest in flawed EBM practices, and not only, but especially, the least cost-effective.(Culyer et al, 2007)  Flawed EBM practices would be those that fail to reach a much higher imposed burden of proof of benefit than currently exists. No longer imposed on the basis of possibilities, as with e.g. the UK NHS breast cancer screening programme (Baum, 2013), but instead ‘not commissioned til proven beneficial beyond reasonable doubt’.

 

This would, secondly, increase the options available to re-invest in re-commissioning care that works (e.g. mental health services for the young, palliative care etc) and for practitioners to communicate with people.

 

Thirdly, the pressure to do this will be helped by insisting the teaching of EBM always includes a real world module on ideology and biopolitical theory.  This would be Real Education for Real EBM, teaching the student practitioners about the way ‘the social’ interacts with real EBM’s most crucial object, namely, the diagnosis, and how capitalist ideology creates the maximalist mindset (Horton, 2017).

 

Baum, M. (2013) The Marmot report: accepting the poisoned chalice. British Journal of Cancer (2013) 00, 1-2, 00: 1-2.

Culyer, A., McCabe, C., Briggs, A., Claxton, K., Buxton, M., & Akehurst, R. (2007) Searching for a threshold, not setting one: The role of the National Institute for Health and Clinical Excellence. Journal of Health Services Research and Policy, 12(1): 3.

Horton, R. (2017) Offline: The Donald Trump Promise. The Lancet, 389(10087): 2360.

Here is an analysis of the underlying causes of healthcare harms and misdiagnosis from Juan from the EBM mailbag discussion list yesterday, and below my attempt to re-phrase this in terms of processes:

-yes, Owen, apparently, EBM has only benefits without harms

-but, how can we “believe” in the application of EBM in the consultation room, in front of the clinico/statistical tragedy 1/ many doctors do not understand health statistics http://library.mpib-berlin.mpg.de/ft/gg/GG_Helping_2008.pdf

2/ many doctors do no know about their patients’ culture, expectations and values http://pubmedcentralcanada.ca/pmcc/articles/PMC4484696/

and 3/ many doctors ignore the principal/agent theory and how to stand in “another’s shoes” so they practice “defensive medicine” (“offensive” from my point of view)

-we need to be more critic with guidelines that have, as in this example, only 9–12% based on the best  quality (Grade A) evidence https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4245184/

-EBM is a god that justify anything in its implementation

 

Juan,

 

Your very useful analysis points us towards some of the most important processes that are contributing to healthcare harms and misdiagnosis.

 

I paraphrase your analysis here as key processes and possible key sites of intervention:

 

1) the education of healthcare workers,

2) the political (de-)regulation of harmful healthcare interventions (the ‘weak’ guidelines as they are euphemistically called), and

3) the power of, and use of rhetoric by, experts (including e.g. GPs) to impose these on unsuspecting patients.

 

The belief of experts in the implementation of EBM is underpinned and dominated by a dominant rational positivist empiricism with a hat tip to ‘values’ (Howick, 2011). Because of this EBM has become a means of production for capitalism. And it is this, ideological, process that produces the predominantly maximalist and technologist mindset described by Groopman. This is the mindset that produces so much harm and misdiagnosis.

 

I suggest that EBM’s fatal flaw, the crisis of EBM, is the failure to consider that ideology in capitalism may be the site of formation of the mindsets, and therefore the values and beliefs, of both experts and patients (Greenhalgh et al, 2014; Kelly et al, 2015). And that it is the mechanisms of ideology in capitalism that requires analysis. But there is a kind of mental block resisting this.

 

Greenhalgh, T., Howick, J., & Maskrey, N. (2014) Evidence based medicine: a movement in crisis? BMJ, 348.

Howick, J. (2011) The Philosophy of Evidence Based Medicine. Chichester: Wiley-Blackwell.

Kelly, M.P., Heath, I., Howick, J., & Greenhalgh, T. (2015) The importance of values in evidence-based medicine. BMC medical ethics, 16(1): 69.