WARNING: Philosophy Alert!
The New Inquisition? Meet Monty Python.
Are you a witch? We will tie your hands and feet then throw you in the water to see if you sink! If you do you were innocent, too bad. If you don't you are a witch, and we have ways to deal with witches. This was a very funny Monty Python skit. Its funny in part because it uses common reasoning - and common fallacies.
"If you have a disability you are faking it" is the implied claim by the current UK government and ATOS. We will cut you off from assistance, and not care if you die. If you don't die you were faking. If you do die, too bad - we need to cut costs and death is a great way to cut costs. Sure the system can be improved. We will get around to it ... eventually. In the meantime lets tweak a few features ... there, we made it better, how can you still be complaining?
Spending a Gold Doubloon to Save a Penny
This is effectively how those with ME and CFS are being treated in the UK, but not just those with neuroimmune diseases or MUSes - most disabled have to face this now. Its a new Inquisition in the worst Monty Python style. If you are disabled then you can work, you just have to be forced to do it. It doesn't matter that you may be dying - dying people have also been assessed as work capable. It doesn't matter if you can't even properly look after yourself or your domicile. It doesn't matter if travel is hugely problematic. It doesn't matter that there are not enough jobs for healthy people. It doesn't matter that most employers are reluctant to hire the disabled and that reluctance will grow to outright hostility if highly disabled people are being forced on them. It doesn't matter that large numbers of people win their appeals to restore benefits - you can cut them off again after only a month, and it can take many months for an appeal. It doesn't matter that all this may cost many times what it saves - they can spin it to sound good. It also doesn't matter that the suicide rate is heading into the stratosphere - thats not genocide, its business as usual.
This is about spending a gold doubloon to save a penny. Its irrational. Its immoral. Its an economic disaster unfolding. Careful rational spending would achieve better outcomes, and it might actually be cheaper to spend more rather than less to get more people off disability incomes.
It can be stopped.
I wonder if I should write a blog comparing the current British Government to the current Syrian Government? How many have died as a result of this? How many are homeless? How many live in torment, fear and profound mistrust of the establishment? This is not business as usual. This is not good government. This is the insane version of economic rationalism - its economic dogma.
The Siren Call.
Something similar is happening with the Dysfunctional Belief Model for CFS.
Sykes has pointed out that the diagnosis of CFS as a mental disorder makes use of what he calls the psychogenic inference. The psychogenic inference uses the following "logic":
"Premise 1. If there is no known physical cause for a
condition, there is no actual physical cause for the
Premise 2. If there is no actual physical cause for the
condition, the cause must be psychological.
Conclusion (The psychogenic inference). If there is no
known physical cause for the condition, the cause must
(p. 312 Functional,Reasons, Neuroscience and the Psychogenic Inference )
Sykes' paper Medically Unexplained Symptoms and the Siren Psychogenic Inference targets the first of these premises. Its not a defensible position. Its also possible, from a strictly logical standpoint, that there is a physical cause that has not been discovered yet. Or that there is a physical cause that has been wrongly dismissed. Or that there are both physical causes and mental causes - so why do they then proceed to ignore the physical?
The psychogenic inference relies either on unexplained symptoms or the lack of a known disorder causing the symptoms. The problem is that most CFS symptoms have physical explanations - you just have to do testing that goes beyond what the hospital system typically provides. So a very real alternative to mental causation is a simple lack of diagnostic and investigatory tests. This is defended on two grounds:
1. It costs too much and often comes up empty, so it is a waste of money.
2. Even if physical problems are found they do not know how to treat it anyway - again a waste of money.
The third through fifth unspoken points are:
3. Its not their problem that the lack of such testing means that patients cannot receive appropriate social support including financial support.
4. Its not their mandate to fund tests to support social claims - OK, maybe it is, but there isn't any funding, what can they do?
5. Its not their fault that they can't treat many of these problems - that requires cutting edge medicine, is often not well validated, requires a better understanding of systems biology which is not taught at medical school, and is often seriously expensive ... where is the money coming from? Who is going to fund this expensive research?
What Sykes does not discuss is the possibility the majority of current psychosomatic medical thinking is wrong. This is a whole other debate, one I will return to later. Sure there are mental issues that cause physical symptoms ... oh, wait, depression is closely associated with physical problems, as is anxiety. It couldn't be that those physical issues are driving the symptoms? No, surely not! Thats buying into the biomedical model, heresy! Sorry to point it out, but the biopsychosocial model does have a bio- part ... oh, and a social part too.
This is not to refute the importance of cognition, mood and behaviour on modifying brain induced symptoms. The brain is plastic, it can change. The physical issues in the brain might therefore be modifiable by various techniques including CBT - but that doesn't necessarily mean the problem is mental. It might be - or not.
So the basis of a psychiatric diagnosis is this: A patient has a psychiatric reason for their CFS unless a known physical cause is found - in which case even a diagnosis of CFS cannot be made as its diagnosed by exclusion. Therefore by definition, not evidence and reason, if they have CFS then they have a psychiatric illness. Case closed.
Or put another way: If you can't prove your not crazy then you must be crazy. They do not have to prove they are right, only that you can't disprove them - but no you can't do any tests. Its a presumption of craziness without evidence. Oh wait, yes, they use a symptom checklist. Presumed psychosomatic patients have these symptoms. If you have these symptoms you must therefore have a psychosomatic illness. Its only invalid if a known alternative illness explains the symptoms, like MS. If you have a physical illness with these symptoms that is not understood ... gosh, no, that could never happen! Sorry to point this out, but how many former psychosomatic illnesses are now known to be physical?
The Happy Happy Easter Bunny.
McLaren had this to say about psychoanalysis in his discussion of Popper:
"In 1922, at the remarkable age of twenty, Popper realized that, intellectually speaking, psychoanalysis was on a par with the Easter Bunny: there was nothing anybody could say or do that would force a committed analyst to admit his theories were wrong." (p. 9)
The DBM is a cognitive and behavioural version of the emotive ideas of Freud. It is an unproven model, and the model is not reality. If you always have an explanation, then nobody can prove to you that the diagnosis is wrong.
McLaren has an alternative model of mental disease based on what he calls a biocognitive model. Its just one of the alternatives out there. Functional medicine is also another model ... and by functional they do not mean psychological, but pertaining to the functional relationships between biochemical pathways and physiology, and based on systems biology. Rituximab, a chemotherapy agent, might be shown to be a cure in phase 3 clinical trials. Antiviral and immunological treatments get results up to an order of magntitude better than DBM treatments - so large that I will argue that an RCT is not required to demonstrate effectiveness. Yet somehow the DBM is considered THE alternative. I will get around to addressing the so called "evidence base" for the DBM in a later blog, including methodological flaws. I also intend to discuss the BPS model, and hope to show that it is likely the DBM has been eclectically crammed into the BPS model - but I am still investigating this and will it be well into next year at least before I have much to say on this.
So the DBM is an unproven, counter-factual and irrational position. Yet it is presented as the only evidence based model, with an implication that therefore it must be correct. I would prefer to believe in the Easter Bunny, I see evidence of the bunny every April.
It would be far more rational for the proponents of the DBM to claim that they have an hypothetical and controversial model with little clinical value, that its still experimental, the outcomes are poor, and that alternative models may have validity. No, what? How could they do that? Hmmm, ethics ...
The Witch, The Python, The Siren and The Bunny
Blog entry posted by alex3619, Apr 23, 2012.
About the Author
I am a long term ME patient with many complications. While I have pushed research advocacy since 1993, I become political around 2009. My current project is a book called "Embracing Uncertainty". Uncertainty in medical science seems anathema to too many doctors. "I do not know" is something more doctors should be honest about.