Medicating the masses
Comments Off on Medicating the masses
by Will Self 
In November of last year I took part in a public debate in London; the motion – which I proposed – was that: “Psychiatrists and the pharmaceutical industry are to blame for the current ‘epidemic’ of mental disorders”. Seconding the motion was Darian Leader, the writer and psychoanalyst; opposing it were Brian Doogan, an executive responsible for marketing antidepressants; and the President of the Royal College of Psychiatrists, Professor Sir Simon Wessely. The format for the debate was that the audience were polled at the outset then at the end to see whether the speeches had had any impact on their beliefs. (And ‘belief’ as I hope to demonstrate in what follows, is surely le mot juste.)
About 40% of the audience agreed with the motion initially, around 20% disagreed and the remainder were undecided. I was wary of presenting a lot of statistical information on the subject, assuming that a non-specialist audience would be unlikely to be swayed by careful analysis of the way meta studies of trial data are massaged by Big Pharma to make the case for drugs that are at best marginally effective, and at worst positively harmful. Nor did I think I’d get far by describing the tentacular infiltration of the medical profession by Big Pharma: its ‘ghost writing’ of academic papers; its junkets for prescribers; and its financing of the very department of the FDA (Food and Drug Administration) responsible for its oversight. Nor did I think it good tactics to harp on such practices as ‘astro-turfing’, whereby drug companies seek to influence the background beliefs of the general population about mental disorders, by insinuating into the broader culture – films, television programmes, even novels – storylines that emphasise the reality of such disorders, and that they’re treatable by psychopharmacological compounds. In part I avoided these tactics because I was confident that my seconder – who has written lucidly and brilliantly on the subject – would do a better job (and indeed he did, he even had copies of the depositions relating to legal suits against Big Pharma); but mostly I eschewed such fact-based arguments because I thought I had a philosophic one about the nature of belief itself that would clinch the matter. My argument went like this: We all accept the idea that it’s possible to believe fervently in an idea (or an ideology) that has no factual basis – such is religious faith. But it can be further argued that religious faith does have two forms of facticity supporting it: the institutional character of religions, and religious rituals themselves, which inculcate belief through what might be termed auto-hypnosis.
As David Bohm and others have remarked, to believe in the sort of implicate order implied by monotheism, it is also necessary to accept suspensions in natural law as willed (so-called miracles), even if one has never personally witnessed such an occurrence. My contention is less a logico-deductive argument than a series of historical-cultural observations: This model of unreasoning belief is, I would contend, either natural to humans, or at any rate so widespread and deeply inculcated that it has greater primacy in belief formation than models based on commonsensical bowdlerisation of the scientific method. (Indeed, my own view is that such ‘true beliefs’, seemingly based on sound empirical testability, are in the common way of experience, still underpinned by faith, since most individuals only have a basic or sketchy idea of standards of scientific proof.) So, humans have a predisposition to believe things – such as facts and ideas – presented to them in ritual contexts and supported by institutions; furthermore, the veracity of certain empirically verifiable beliefs is held to be commensurate with the veracity of miracles – they partake of the same overall ‘truth field’. So, how does an individual with such a system of belief (as opposed to belief system) respond when the unverifiable – and un-witnessed – miracles, are replaced by verifiable and readily observed ones; surely, only by strengthening their convictions. If you could quantify such things, to how much greater an extent would you imagine people ‘have faith’ in medical science now than their ancestors did in Christianity circa 1850?
Writing in his book Being Mortal, the surgeon and public health policymaker, Atul Gawande, questioned our society’s inability to confront mortality, and our reliance on medical science to squeeze the last drops of consciousness from our ailing bodies; yet he also observed that from an extra-social – or anthropological – perspective, the advances in medicine since 1950 do appear miraculous: transplant operations, brain surgery, stem cell therapies – these are all procedures that can prolong life where once death was inevitable. Indeed, why stop at 1950? If we go back another thirty years, to before the discovery of antibiotics, we’re living in a world in which sepsis itself can be a death sentence. So, why wouldn’t people believe in medicine and have faith in doctors? Why wouldn’t depressed patients who are given prescriptions for SSRIs (selective serotonin reuptake inhibitors) by their GPs believe that they work, and in so believing experience the amelioration of their depressive symptoms? The fact that there is currently no understanding of what a chemical basis for depression might be, or how SSRIs might act to alleviate it (the low serotonin hypothesis has long since been discredited), is neither here nor there; nor is it of any significance that SSRIs only marginally out-perform psychotherapy, cognitive behavioural therapy, a walk, or a chat with a friend, when it comes to improving depressives’ mental states.
That even the marketing director of a company that manufactures a well-known antidepressant was unable to present any causal explanation for the drugs ‘success’ when I interviewed him, but rather averred there was only a ‘statistical correlation’ between its administration and symptomatic alleviation, was, in my view, equally irrelevant. Irrelevant, that is, when set beside the key forms of facticity underpinning patients’ belief that it does work – a belief that is, undoubtedly, a self-fulfilling prophecy. To rail against the institution of government is one thing – its claims to be protecting and nurturing us are ever open to challenge; organised religions continue to haemorrhage institutional authority, while their rituals still offer succour to millions. But to disbelieve in the nexus of institutions – in Britain the National Health Service, associated professional bodies, and of course the drug companies – that constitute ‘medicine’, would be to resile from the most powerful, conviction-inducing ritual that there currently is: the doctor’s consultation. To disbelieve in the efficacy of psychopharmacology, whether it be axyolitic drugs aimed at busy neurotics, or hypnotics and tranquilisers designed to calm troublesome psychotics, is by association to challenge the potency of antibiotics – and who in their right mind would wish to do that? Speaking for myself, antibiotics have saved my life on at least four occasions – probably more; even as I write this I’m on a course of antibiotics for a septic toe, and praying fervently that it will work. When I asked my own, much-loved GP why it was that he prescribed SSRIs he said: “Because they work.” He wasn’t averse to considering that they’re efficacious because of the placebo effect, or the nocebo one either (the nocebo effect occurs when patients respond positively to the negative side effects of a drug), but as a clinician all that mattered to him was that his patients stopped being miserable. I’ve no doubt that his position is a common one: doctors like curing patients, but unlike priests they seem to have little problem with engaging in a ritual they don’t believe in – what’s termed ‘burnout’ in the medical profession should probably be called ‘loss of faith’.
Writing in the British Journal of Medicine, the highly-respected former president of the Royal College of General Practitioners, Dr Iona Heath, had this to say: “Underpinned by webs of financial imperatives and conflicted interests, over-diagnosis and overtreatment have become disturbingly pervasive within contemporary medicine and are now deeply embedded within healthcare systems around the world.” Heath’s analysis continues: she sees the chief villain as the medical technology industry, whose advancing capacity to “measure and assign numbers to an ever-increasing number of biometric parameters” has resulted in the “continual pressure to extend the range of abnormal, shifting the demarcation point further into the territory previously considered normal.” This business of the abnormal being extended into the normal is registered in psychiatry by the way ‘mental diseases’ are reverse engineered: a drug is discovered that alleviates some symptoms; these symptoms are grouped together into a ‘pathology’, which is then sanctified by inclusion in the American Psychiatric Association’s Bible, the Diagnostic and Statistical Manual of Mental Disorders; the necessary treatment for this new malady is, of course, close to hand – as is the practitioner’s prescription pad.
Really, it’s quite pointless to try and dismantle this apparatus of bogosity using reason – because as I think I’ve already pointed out: it rests securely on an unshakeable faith. Not just faith in medicine, but another form of faith as well: faith in the market. Indeed, the more you compare the two kinds of faith, the more neoliberalism and medical science seem to have been seamlessly merged into a syncretic religion it would take a Dun Scotus to unpick. One way of understanding this syncretism is through the concept of commoditisation: with medical science playing the part of commoditising the human body; but I think a more productive heuristic comes from sociology, and takes the form of professional closure. Certainly doctors have been creating diseases for as long as there’s been medicine, but it’s only since the profession achieved effective closure that those diseases have become endemic – indeed, have become wholly unnoticed as being iatrogenic (that is, caused by treatment) at all. Surely this can only be because we have become so inured to the other effects of professional closure in our society: looked at through the paradigm of medicine, what are the periodic crises of late capitalism if not the iatrogenic diseases produced by financiers, financial analysts and economists? And just as miscarriages of justice and our metastasising prison system are a function of the legal profession’s closure; so substandard foods, stuffed with salt and sugar, owe their existence to highly-respected members of the food-processing industry. We are all inhabitants now of Planet Iatrogenic: a strange dirt ball indeed, where the billions of beings conjured into longevity by drugs and phosphates are subjected to the unintended malaises consequent upon their own expertise. As I was making my argument at the debate I became increasingly conscious of a vocal claque on the left side of the hall who were in no mood to listen: they heckled, they groaned – they particularly objected to my talking of the ‘faith’ patients have in their doctors. When the final vote was taken it transpired there had been a massive swing to those opposing the motion, so that Darian Leader and I lost.
A couple of days later the organisers of the debate sent me an email from a woman in the audience who had heard someone near her say that he had registered as ‘undecided’ at the beginning of the debate simply so he could vote against it at the end. As this informant tuned in to the conversations around her she realised that this man was not alone: there was a significant section of the audience who were doing the same thing. Who were these people who were so determined to rig a public debate in favour of the psychiatric profession and its associated drug dealers? I’m pretty certain that you can guess the answer – and I only hope it doesn’t shake your faith in them, because on Planet Iatrogenic faith is a matter of life and death.
About 40% of the audience agreed with the motion initially, around 20% disagreed and the remainder were undecided. I was wary of presenting a lot of statistical information on the subject, assuming that a non-specialist audience would be unlikely to be swayed by careful analysis of the way meta studies of trial data are massaged by Big Pharma to make the case for drugs that are at best marginally effective, and at worst positively harmful. Nor did I think I’d get far by describing the tentacular infiltration of the medical profession by Big Pharma: its ‘ghost writing’ of academic papers; its junkets for prescribers; and its financing of the very department of the FDA (Food and Drug Administration) responsible for its oversight. Nor did I think it good tactics to harp on such practices as ‘astro-turfing’, whereby drug companies seek to influence the background beliefs of the general population about mental disorders, by insinuating into the broader culture – films, television programmes, even novels – storylines that emphasise the reality of such disorders, and that they’re treatable by psychopharmacological compounds. In part I avoided these tactics because I was confident that my seconder – who has written lucidly and brilliantly on the subject – would do a better job (and indeed he did, he even had copies of the depositions relating to legal suits against Big Pharma); but mostly I eschewed such fact-based arguments because I thought I had a philosophic one about the nature of belief itself that would clinch the matter. My argument went like this: We all accept the idea that it’s possible to believe fervently in an idea (or an ideology) that has no factual basis – such is religious faith. But it can be further argued that religious faith does have two forms of facticity supporting it: the institutional character of religions, and religious rituals themselves, which inculcate belief through what might be termed auto-hypnosis.
As David Bohm and others have remarked, to believe in the sort of implicate order implied by monotheism, it is also necessary to accept suspensions in natural law as willed (so-called miracles), even if one has never personally witnessed such an occurrence. My contention is less a logico-deductive argument than a series of historical-cultural observations: This model of unreasoning belief is, I would contend, either natural to humans, or at any rate so widespread and deeply inculcated that it has greater primacy in belief formation than models based on commonsensical bowdlerisation of the scientific method. (Indeed, my own view is that such ‘true beliefs’, seemingly based on sound empirical testability, are in the common way of experience, still underpinned by faith, since most individuals only have a basic or sketchy idea of standards of scientific proof.) So, humans have a predisposition to believe things – such as facts and ideas – presented to them in ritual contexts and supported by institutions; furthermore, the veracity of certain empirically verifiable beliefs is held to be commensurate with the veracity of miracles – they partake of the same overall ‘truth field’. So, how does an individual with such a system of belief (as opposed to belief system) respond when the unverifiable – and un-witnessed – miracles, are replaced by verifiable and readily observed ones; surely, only by strengthening their convictions. If you could quantify such things, to how much greater an extent would you imagine people ‘have faith’ in medical science now than their ancestors did in Christianity circa 1850?
Writing in his book Being Mortal, the surgeon and public health policymaker, Atul Gawande, questioned our society’s inability to confront mortality, and our reliance on medical science to squeeze the last drops of consciousness from our ailing bodies; yet he also observed that from an extra-social – or anthropological – perspective, the advances in medicine since 1950 do appear miraculous: transplant operations, brain surgery, stem cell therapies – these are all procedures that can prolong life where once death was inevitable. Indeed, why stop at 1950? If we go back another thirty years, to before the discovery of antibiotics, we’re living in a world in which sepsis itself can be a death sentence. So, why wouldn’t people believe in medicine and have faith in doctors? Why wouldn’t depressed patients who are given prescriptions for SSRIs (selective serotonin reuptake inhibitors) by their GPs believe that they work, and in so believing experience the amelioration of their depressive symptoms? The fact that there is currently no understanding of what a chemical basis for depression might be, or how SSRIs might act to alleviate it (the low serotonin hypothesis has long since been discredited), is neither here nor there; nor is it of any significance that SSRIs only marginally out-perform psychotherapy, cognitive behavioural therapy, a walk, or a chat with a friend, when it comes to improving depressives’ mental states.
That even the marketing director of a company that manufactures a well-known antidepressant was unable to present any causal explanation for the drugs ‘success’ when I interviewed him, but rather averred there was only a ‘statistical correlation’ between its administration and symptomatic alleviation, was, in my view, equally irrelevant. Irrelevant, that is, when set beside the key forms of facticity underpinning patients’ belief that it does work – a belief that is, undoubtedly, a self-fulfilling prophecy. To rail against the institution of government is one thing – its claims to be protecting and nurturing us are ever open to challenge; organised religions continue to haemorrhage institutional authority, while their rituals still offer succour to millions. But to disbelieve in the nexus of institutions – in Britain the National Health Service, associated professional bodies, and of course the drug companies – that constitute ‘medicine’, would be to resile from the most powerful, conviction-inducing ritual that there currently is: the doctor’s consultation. To disbelieve in the efficacy of psychopharmacology, whether it be axyolitic drugs aimed at busy neurotics, or hypnotics and tranquilisers designed to calm troublesome psychotics, is by association to challenge the potency of antibiotics – and who in their right mind would wish to do that? Speaking for myself, antibiotics have saved my life on at least four occasions – probably more; even as I write this I’m on a course of antibiotics for a septic toe, and praying fervently that it will work. When I asked my own, much-loved GP why it was that he prescribed SSRIs he said: “Because they work.” He wasn’t averse to considering that they’re efficacious because of the placebo effect, or the nocebo one either (the nocebo effect occurs when patients respond positively to the negative side effects of a drug), but as a clinician all that mattered to him was that his patients stopped being miserable. I’ve no doubt that his position is a common one: doctors like curing patients, but unlike priests they seem to have little problem with engaging in a ritual they don’t believe in – what’s termed ‘burnout’ in the medical profession should probably be called ‘loss of faith’.
Writing in the British Journal of Medicine, the highly-respected former president of the Royal College of General Practitioners, Dr Iona Heath, had this to say: “Underpinned by webs of financial imperatives and conflicted interests, over-diagnosis and overtreatment have become disturbingly pervasive within contemporary medicine and are now deeply embedded within healthcare systems around the world.” Heath’s analysis continues: she sees the chief villain as the medical technology industry, whose advancing capacity to “measure and assign numbers to an ever-increasing number of biometric parameters” has resulted in the “continual pressure to extend the range of abnormal, shifting the demarcation point further into the territory previously considered normal.” This business of the abnormal being extended into the normal is registered in psychiatry by the way ‘mental diseases’ are reverse engineered: a drug is discovered that alleviates some symptoms; these symptoms are grouped together into a ‘pathology’, which is then sanctified by inclusion in the American Psychiatric Association’s Bible, the Diagnostic and Statistical Manual of Mental Disorders; the necessary treatment for this new malady is, of course, close to hand – as is the practitioner’s prescription pad.
Really, it’s quite pointless to try and dismantle this apparatus of bogosity using reason – because as I think I’ve already pointed out: it rests securely on an unshakeable faith. Not just faith in medicine, but another form of faith as well: faith in the market. Indeed, the more you compare the two kinds of faith, the more neoliberalism and medical science seem to have been seamlessly merged into a syncretic religion it would take a Dun Scotus to unpick. One way of understanding this syncretism is through the concept of commoditisation: with medical science playing the part of commoditising the human body; but I think a more productive heuristic comes from sociology, and takes the form of professional closure. Certainly doctors have been creating diseases for as long as there’s been medicine, but it’s only since the profession achieved effective closure that those diseases have become endemic – indeed, have become wholly unnoticed as being iatrogenic (that is, caused by treatment) at all. Surely this can only be because we have become so inured to the other effects of professional closure in our society: looked at through the paradigm of medicine, what are the periodic crises of late capitalism if not the iatrogenic diseases produced by financiers, financial analysts and economists? And just as miscarriages of justice and our metastasising prison system are a function of the legal profession’s closure; so substandard foods, stuffed with salt and sugar, owe their existence to highly-respected members of the food-processing industry. We are all inhabitants now of Planet Iatrogenic: a strange dirt ball indeed, where the billions of beings conjured into longevity by drugs and phosphates are subjected to the unintended malaises consequent upon their own expertise. As I was making my argument at the debate I became increasingly conscious of a vocal claque on the left side of the hall who were in no mood to listen: they heckled, they groaned – they particularly objected to my talking of the ‘faith’ patients have in their doctors. When the final vote was taken it transpired there had been a massive swing to those opposing the motion, so that Darian Leader and I lost.
A couple of days later the organisers of the debate sent me an email from a woman in the audience who had heard someone near her say that he had registered as ‘undecided’ at the beginning of the debate simply so he could vote against it at the end. As this informant tuned in to the conversations around her she realised that this man was not alone: there was a significant section of the audience who were doing the same thing. Who were these people who were so determined to rig a public debate in favour of the psychiatric profession and its associated drug dealers? I’m pretty certain that you can guess the answer – and I only hope it doesn’t shake your faith in them, because on Planet Iatrogenic faith is a matter of life and death.
