Tag: overdiagnosis

Fodder for Medical Perverts – Zizekian?

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

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

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

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

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

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

Misrecognition is Medicine’s Truth

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

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

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

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

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

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

The Sublime Object of Medicine

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

“All Power is through the illusion of knowledge”

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

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

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