Georg Ivanovas From Autism to Humanism - systems theory in medicine

4. Systemic Basics

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4.6 Second-order cybernetics in medicine

The influence of the observer onto the observed is a well-known topic in physics. This effect is much more prominent in medicine, although there is little awareness of this fact. The so-called second-order cybernetics investigates this interaction between the observer and the observed.

Von Foerster defined first-order cybernetics as “the cybernetics of observed systems” and second-order cybernetics as “the cybernetics of observing systems” (von Foerster 1995: 1). That is, the observer is also integrated in a cybernetic system and his knowledge gained by observing is not objective but a subjective construction based on cognitive and social processes. This is a break with the traditional idea that there is an objective organization or structure that can be definitely investigated (Bunge 1979: 203-209). In its final consequence facts are no objective findings but only subjective perceptions (Simon 1993: 151-156). Findings are a ‘construction ‘or even an ‘intervention’ (von Foerster/Bröcker 2002).

A first-order or decidable question would be whether or not there are reference values for serum iron, how the thyroid gland is regulated, how a transplantation is best done, what virus brings on SARS.

Second-order cybernetics in medicine investigates how the observer creates a situation that leads to certain results. The self fulfilling prophecies belong into this category, or the placebo effect. Second-order cybernetics also analyses the pattern how phenomena are defined as ‘ill’ or as ‘healthy’ (Simon, 1995: 12) and on which basis a therapeutic strategy is chosen.

The idea that diseases are invented makes normally no sense in the medical context or only in these cases where diseases are created for marketing or fame purposes. An outstanding example was the in German born ‘Sissi syndrome’, introduced by then SmithKlineBeecham 1998. Patients – it was the estimation that up to three millions suffered from this syndrome – were said to be severely depressed thus needing antidepressant therapy. The only problem was that Sissi syndrome patients do not admit their depression, but cover it by being very active and optimistic. According to the resonance in the media it must have been a good business for the company. It lasted five years until the swindle was discovered. (Blech 2003: 15). The same syndrome was discussed for the Anglo-Saxon world under the name ‘Princess Di syndrome’ but did not make it at the end (Tuffs 2003).

When the inventions are not so obvious they are called ‘disease mongering’. It “is the selling of sickness that widens the boundaries of illness and grows the markets for those who sell and deliver treatments”. But it is not limited to drug companies but involves “alliances of pharmaceutical corporations, public relations companies, doctors' groups, and patient advocates (to) promote these ideas to the public and policymakers—often using mass media to push a certain view of a particular health problem” (Moynihan/Henry 2006). Classical examples are the quite new female dysfunction (Lewis 2005) and male sexuality erectile dysfunction which was redefined by drug companies (Lexchin 2006) leading to a medicalisation of sexual life (Tiefer 2006). Rather controversially discussed is the fibromyalgie syndrome. Drug companies, drug related physicians and suffering patients maintain that the syndrome ‘exists’ whereas scientists tend to negate its existence as an independent disease (Berenson 2008a). Many others, often socially not so important diseases are mongered such as the pseudobulbar effect, an uncontrolled laughing in neurological disease (Spiegel online 2005) or the restless leg syndrome (Woloshin/Shwartz 2006).

A second order analysis is not concerned with the question whether or not such diseases ‘exist’. Existence is no issue in this line of reasoning as everything is regarded as more or less invented. More interesting are the implications and the mechanisms which maintain the idea of an existence, the way how conclusions are taken, the interplay of different factors like technique, interest and theory.

Does attention deficit hyperactive disorder (ADHD) exist? According to the current logic yes, as there are hyperactive children, certain criteria, an ICD-10 key (chap. 2.1.e) and the agreement of the medical community. This existence leads to an inappropriate medicalisation of educational performance involving the teachers (Phillips 2006). About 4 million children are treated in the US and may be another million illegally (Aldhous 2006). That is, the boarders between real concern, the invention of criteria and mongering is somehow fluent.

The attempts to oppose mongering (Heath 2006, Mintzes 2006) and/or the medicalisation of medicine represent a typical negative feedback loop. They are an essential part of the cybernetics of the observing system in medicine.

The following examples aim to show how ‘medical knowledge’ is created. They shall demonstrate the inherent mechanisms, tendencies, logical structures. The details are not as important, nor whether certain statements are finally true or not.


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