An ideological critique - the failure of regulation and the root causes of overtreatment and overdiagnosis
14 February 2013
A GlaxoSmithKline memo, following a series of trials of Paroxetine (an antidepressant in adults) in children, demonstrating a lack of effect, stated: “It would be commercially unacceptable to include a statement that efficacy had not been demonstrated as this would undermine the profile of Paroxetine’. (1) Nonetheless, in the year after this memo, 32,000 prescriptions for Paroxetine were issued to children in the UK. (1) Thus, commercial success or the idea: ‘profit’ is signified as coming before health need.
The editorial by Davis and Abraham, the personal view by Gotzsche, and the book Bad Pharma by Goldacre, all document the failure of regulation to control ‘overtreatment’ (and by implication overdiagnosis), and call for more regulation as the solution.(2,3,4) This failure enables huge ‘overtreatment’ and ‘overdiagnosis’. (5,6) The approach here identifies incoherencies and non-sense, and argues that regulation must always fail unless the market boundaries change so that the profit motive is removed. (7)
The subject and ideology – punishing the individual
In our ruling ideology (after Althusser), the ‘employees’ (including doctors) of the drugs industry are hailed by the idea: ‘profit’, and ‘good’ subjects ‘believe’ that their rightful work is to maximise ‘profit’, and ‘profit’ becomes the subject’s idea. Gotzsche calls for greater punishment of individuals. But if these individuals sincerely believe in what they are doing, what the ideology hails them to do, what would punishment achieve other than a distracting scapegoating? Gotzsche implies that these individuals are free and autonomous authors of their own choices, but this ignores the possibility as argued here, after Lacan, that we are all constituted by alienation from ourselves by our essential use of language in order to act in the world within a real symbolic structure that has determining effects upon our actions. (8,9)
Complicit doctors – subjects working to maintain the relations of production
Gotzsche also talks about unethical ‘complicit’ doctors. (3) To be complicit implies a passive role, an agreement ‘to be induced’ or ‘paid’ to take part in somebody else’s project, perhaps to be less guilty. His request for doctors to not comply suggests that doctors are somehow different from the company executives. Does this play into a fantasy that doctors are more capable of being ethical than other subjects and yet aren’t doctors just as much subjects of the ruling ideology, just as driven by the idea: ‘profit’ as anybody else? As proxy consumers of the drug industry doctors are just as subjected to or interpellated by ideology, by the ‘moment of consumption’ as anybody else. Thus this fantasy blinds us to the doctors’ subjection to the idea: ‘profit’, it prevents doctors from questioning the ideology itself.
Courts and bankruptcy - Politicians and burdens – Business must not be allowed to fail
Davis and Abraham suggest that (2):
….courts might be reluctant to impose penalties that would threaten the financial survival of companies.
……….additional funding for FDA funding for fraud detection …..similar shifts are less likely in the UK given the government’s determination to ‘reduce burdens on business’.
……..regulators have been encouraged by governments to be responsive to the commercial interests of industry…….
These concepts signify the drug industry as: ‘must not be allowed to fail’ at any cost – even if innocent people are being harmed - failure would reveal the ruling ideology to be flawed, in a state of collapse, and this would be politically dangerous. This implies that regulation within the ruling ideology is bound to always fail, perhaps because it itself is part of the ideological state apparatus supporting the ruling ideology and its idea: ‘profit’.
Market boundaries – need before profit
Is it possible that regulation could and will never work without radical changes to the economic and political systems? Is it possible that shifting the boundary between the state and the market, between public and private ownership might provide part of a solution. Shutt, an economist and author commented upon Goldacre’s Bad Pharma (1,10):
…….this is an industry totally unsuited to being run on profit maximising lines by conventional shareholding companies …… why not spell out the vital necessity of locating it within publicly owned/non-profit organisations where there need be no obstacle to full transparency’
This isn’t to recommend a central command ‘soviet’ style economy, instead it would be similar to a nationalisation of the railways as exists in much of Europe, (where the railways work more efficiently than in the fragmented UK system). (1) This would shift the market boundary making the idea dominating the industry more ‘need’ and less ‘profit’.
To combat overtreatment and overdiagnosis it seems clear that more science by evidence creators, more evidence based consuming, and more regulation, on their own, will fail absolutely. The profit motive within the healthcare market will continue to do huge amounts of harm in a systematic way unless the profit motive is radically challenged in this particular market sphere.
(1) Cromwell, D. Bad Pharma, Bad Journalism. http://www.medialens.org/index.php/alerts/alert-archive/2012/702-bad-pha...
(2) Davis C, Abraham J. Is there a cure for corporate crime in the drug industry? BMJ 2013;346:f755
(3) Gotzsche P. Big pharma often commits corporate crime, and this must be stopped. BMJ2012;345:e8462
(4) Goldacre B. Bad Pharma: How drug companies mislead doctors and harm patients. Fourth Estate, 2012 (UK).
(5) Moynihan R, Doust J, Henry D. Preventing overdiagnosis: how to stop harming the
(6) Greenhalgh T. Why do we always end up here? Evidence-based medicine's conceptual cul-de-sacs and some off-road alternative routes. J Prim Health Care 2011; 4(2):92-97.
(7) Althusser L. For Marx. Harmondsworth: Penguin books; 1969.
(8) Parker I. Lacanian Discourse Analysis in Psychology - Seven Theoretical Elements.
Theoryand psychology 2005; 15(2):163-182.
(9) Pavon Cuellar D. From the Conscious Interior to an Exterior Unconscious. London: Karnac Books Ltd; 2010.
(10) Shutt, H. Beyond the profits system – possibilities for a post-capitalist era. 2010 Zed Books Ltd. London.
Competing interests: PhD student: Overdiagnosis and EBM - positivism, ideology and the subject - a Lacanian/Althusserian discourse analysis
Manchester metropolitan University, Manchester
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