From the impasses of state deontology to medical ethics

Scientism

If the sciences can be proud of their relationship with truth, and through it, find their value, let us not forget that culturally their constitution comes in response to the uncertainty that is part of the lived experience of each man. Faced with the contingency of existence and anguish, man has deployed various responses, of which science is one. In this respect, its predictive capacity is sometimes called upon as a response. The crisis we are going through must obviously lead us to question the roots of this faith in scientific, but above all technical, development as a source of decision-making criteria and as the organizing powers of our societies, i.e., of our way of living together.

Like any discipline, public health epidemiology cannot be unanimous. Science without debate is scientism. It should be remembered that doubt is one of the foundations of the scientific process. Dissensus is therefore necessary first so that a consensus can be established later. Within our society, dissensus on vaccination has never been able to emerge. There has been no public debate on vaccination. The peremptory argument “It’s scientific” has been waved by many, like an incantation, with the sole aim of cutting off speech. As Lacan once wrote, “I speak the truth”[1]. The truth is foremost speaking, but what guarantee does the word offer? There is no guarantee. Truth or falsehood are not intrinsic qualities of language. We do not know, when the other speaks, whether he is lying or telling the truth. Perhaps, in fact, he is telling the truth. The invention of the lie detector tried to compensate for this defect, unsuccessfully.

Science is therefore part of a long time frame, and cannot confuse the time of discovery with that of justification. Citizens, whether frail or healthy, have nevertheless all been invited to believe in the good news. As of December 2020, older people were encouraged to be vaccinated, even though at the time no study could prove the vaccine’s effectiveness in this age group[2]. 2] Since then, observational research has shown the benefits of vaccination in the elderly, but who can guarantee that there will be no undesirable medium- or long-term effects on younger people? Children and adolescents will not have to live 10, 20 or 30 years with the vaccine, but 50, 60 or 70 years. To the sophists who claimed universal knowledge in Ancient Greece, Socrates replied, “I know that I know nothing”. Today, the new sophists are more trivially called “experts”.

Let us remember that prediction is a difficult art in science. Modelling in epidemiology is certainly one of the most perilous exercises (see Figure 1). However, it has regularly been used to justify drastic health measures, even though it is not recognized by the French National Authority for Health as a method with a high level of proof (according to the HAS-guide to good practice[3]). The retrospective evaluation of these models by the Polytechnic engineers (Langevin & Stark[4]) reveals their failure to predict what will happen in 9 out of 11 cases. The models of Imperial College, the Pasteur Institute and Inserm overestimate the number of deaths, the number of hospitalizations and the occupancy rate of critical care beds (see Figure 2). Citizens, deprived of the most basic freedoms (such as direct access to various public spaces), are therefore entitled to question the interest of the measures taken, which have also largely contributed to worrying the general population about the danger of the virus. To castigate anger is to overlook the fact that some of it is legitimate.

The first wave provided early evidence that severe cases and mortality are favoured by known factors: age, obesity, even overweight and comorbidities. For the year 2020, no excess mortality was observed in the under 65s. Technically, therefore, we are not facing a pandemic, but a syndemic. This term is used in public health when the expression of a disease in a population is conditioned by biological or environmental factors that aggravate the expression of a disease. Dr Richard Horton, a member of the Lancet editorial board, reminds us of this in one of his editorials[5].

In this health crisis, which has become a political crisis, the moral and universal incitement to vaccination joyfully tramples on the most elementary principles of public health. Children and adolescents have been invited to be vaccinated, not for their benefit (since the individual benefit has not been demonstrated in this age group) but for the benefit of older people. This is nothing less than a political instrumentalization of the youngest, which runs counter to the most essential ethics in health matters[6]. Vaccination is therefore not intended to protect children, a vulnerable population, but to protect adults. The collective benefit prevails over the individual benefit, and the break with ethics is complete. The communication around the vaccine has thus served one purpose: mass, indiscriminate vaccination. We note that the truth, unlike a lie, serves no purpose. This is the lesson of the allegory of truth crossing the path of lies.

People get vaccinated for three reasons: (1) if they believe that vaccination offers them a personal benefit, (2) if they assume that vaccination is effective, and (3) if they believe that the vaccine is free of adverse effects. The incentive to vaccinate the youngest members of the population has therefore been achieved through relentless communication that reinforces the feeling of vulnerability to Covid-19 (fear strategy), exaggerated benefits of the vaccine (with commercial slogans such as “All vaccinated, all protected”, a gratuitous statement that does not refer to any serious scientific argument), and finally minimization of the undesirable effects (another advertising slogan “The vaccine can have desirable effects”). Let us recall Bernard Begaud (1994), the father of French pharmacovigilance:

For most empirical situations occurring in the post-marketing surveillance setting, the expected number remains low and only a maximum of one to three cases could be accepted as possibly coincidental.

Begaud, 1994^[7]

Haven’t we long since exceeded the absolute value of three? In Luxembourg, more than 2,000 adverse events were recorded in 2021, compared to 92 in 2020[8]. Even in relation to the proportion of people vaccinated, we are faced with the most harmful treatment in the history of medicine.

From blackmail to freedom

Despite the numerous calls for moderation by several scientists, politicians have juggled freedom and health on a whim. One cannot be achieved without the other or at the expense of the other. This opposition, which has no scientific basis, is a rhetorical exercise that constitutes a major departure from the ethics and practice of medicine. Lacan reminds us, in his seminar on Ethics, of the complacency of the moral requirement:

[…] there is very often, in what man imposes on himself as duties, only the fear of the risks to be taken if one does not impose them on oneself. We have to call things by their name and it is not because we put them behind a triple analytical veil, that this is not what it means – what the analysis articulates is that, basically, it is more convenient to be submit oneself to the ban than to incur castration.

Lancan, séminaire sur l’Éthique, p. 354, 1960^[9]

In other words, it seems more convenient to obey than to confront the possibility of loss. Loss of life, loss of health, loss of a certain number of satisfactions. Duly noted. However, our society will have to get used to the risk of death again if it does not want to sink into a rigid cadaveric state. Death is necessary for all life.

The medicine that has been proposed to us during this health crisis, through vaccination for all, is a medicine without a clinic. A medicine that deals with an organism, without age, without particularity, without comorbidity, without weight, without history, without associated pathology, without allergy. A medicine without a doctor and without a patient. A dehumanizing medicine. A prerequisite for inaugurating health to which freedom is promptly sacrificed. The medical act of vaccination has thus become a political act.

The totalitarian temptation of medical practice is not new. Skrabanek[10], a professor of medicine at Trinity College, denounced the “creeping totalitarianism” of the “cult of superhealth” (biostylism) in 1997, with the danger of a collective standardization of behaviours erected as state policy. This health crisis, beyond the rupture it has created, is therefore part of a certain continuity of a movement that began several decades ago. For Hannah Arendt, totalitarianism is qualified as such not because of the repression or the crimes committed, but because of its capacity to interfere in the intimate, family sphere. This is also the reason why Roland Gori spoke of “totalitarian health” in 2005[11]. Medicine has long since taken over the private sphere. Through self-care, it tells us what we should eat, smoke or drink. Moral rationalism has done the rest by joining easily internalized injunctions: I eat too much, I drink too much, I smoke too much, I don’t move enough, I don’t do enough sport, etc. The normalization and moralization of behaviour already begins here. Note that the feeling of obligation is supported by the feeling of guilt. Freud makes the surprising observation in Malaise in Civilization that the more the subject respects the moral law, the more his obligations are reinforced and the more his guilt grows. Like a spiral.

On the perversion of Kantian deontology

The notion of duty, so frequently cited by Dr. Rauchs, refers to a sphere of moral philosophy that is Kantian deontology. Kant’s position was diametrically opposed to that of the consequentialists for whom “the end justifies the means”. Rather, Kant believed that actions were good or bad in themselves, regardless of their outcome. The fact that a morally reprehensible act (restricting access to public space, suspending carers, etc.) may have positive consequences, does not make that act morally good. Kant therefore proposed that we use the rational dimension of our mind to develop a set of moral rules that would be universally true. A radical position that is stated with a “Thou shalt” while aiming at the Absolute Good. A sort of empty statement, finally, since the only requirement is the universality of the Good. Once these rules have been elaborated, it would then be our moral duty to follow them no matter what.

Let us observe how these rules have been hijacked for the benefit of an authoritarian system to become rules to be followed in all cases, without ever questioning the right or wrong of their basis.

The new medical deontology can be summarized as follows: “Respect and apply the protocols” established under the guise of scientificity and “good conduct”. This is a perverted form of ethics. This deontology makes it possible to inflict harm on others without arousing the slightest remorse and, as a bonus, to feel virtuous when applying it according to the common idea: “It’s a dirty job, but it has to be done”. This is how nursing home managers refused to allow relatives to visit their residents because they did not have the precious sesame; how French administrations were able to suspend carers without batting an eyelid; how doctors thought they were doing good by not visiting their patients, who were confined and treated with Doliprane. The moral significance of the acts is not mentioned.

Isn’t that what Dr Paul Rauchs means when he encourages politicians to impose vaccination for all? “It’s a dirty job, but it has to be done. This perversion of deontology allows political decision-makers to feel virtuous without ever questioning the moral meaning of compulsory vaccination. Kant would certainly turn in his grave.

The establishment of protocols and procedures, so common in our society today, allows people to feel free of responsibility for their actions and words, since they are no longer a matter of personal choice. Right and wrong are reduced to compliance with protocol. Hannah Arendt called this “the banality of evil”. The deontology that is therefore imposed in this health crisis is by definition anti-ethical because there can be no ethics without reflection of the subject on his action.

If Jacques Lacan drew our attention to the fact that medicine cannot function without the patient assuming knowledge from the doctor, it is not to encourage the dissymmetry of the relationship. Free and informed consent must be loyal to the patient to break the omnipotence imputed to the doctor. Is this not what our society should be aiming for, to get away from the infantilization of the relationship with the other?

Notes

[1] Lacan, J. (1966). La chose Freudienne – 1955. In J. Lacan (Ed.) Les écrits (pp.401-436). Paris : Seuil

[2] https://pubmed.ncbi.nlm.nih.gov/33301246/

[3] https://www.has-sante.fr/jcms/c_1600564/fr/niveau-de-preuve-et-gradation-des-recommandations-de-bonne-pratique-etat-des-lieux

[4] https://evaluation-modelisation-covid.github.io/france/

[5] Norton, R. (2020). Covid-19 is not a pandemic. The Lancet, 396, p. 874

[6] While morality is prescriptive and universal (what is good for everyone at all times), ethics is a-normative and free from any obligation (what is good for one person at one time may not be good for another person at the same time).

[7] Begaud, B., Moride, Y., Tubert-Bitter, P., Chaslerie, A. & Haramburu, F. (1994). False positives in spontaneous reporting: should we worry about them? British Journal of Clinical Pharmacology, 38(5), 401-404. doi: 10.1111/j.1365-2125.1994.tb04373.x

[8] UMC: Get to know UMC https://who-umc.org/about-uppsala-monitoring-centre/

[9] Lacan, J. (1986). Le séminaire, livre VII, L’éthique de la psychanalyse (1959-1960). Paris : Seuil

[10] Skrabanek, P. & Mc Cormick, J. (1989). Idées folles, idées fausses en médecine. Paris : Odile Jacob

[11] Gori, R. (2005).