During the 90s, newspapers proclaimed a society of joy in Europe. It was the time of the new economy, techno raves, new extreme sports, neon clothes and, more importantly, the fall of the iron curtain. The euphoric mood was not unique to Europe, but rather, to the Western World. While many considered this to be an era of joy, two philosophers addressed a darkness within that movement of hedonism. Their ideas might still apply to society and in particular to medical practice.
In his theory, Slavoj Zizek reminds us of the Lacanian superego. He argues this superego, commonly said to be the root of rules and norms, is characterized by its exertion of power, a dark and evil entity. In order to feel pleasure or joy, humans had to revolt against their internalized rules. Joy could only be present in the lights of guilt and shame. Thus, pleasure was always connected to punishment. However, the nineties inspired a change in this outdated view. The modern superego, while still dark and evil, transformed. Today, enjoyment has become the rule. If we are unable to enjoy our lives, we penalize ourselves, resulting in a wide array of symptoms. Mental and sometimes physical symptoms follow.
The course of enjoyment can be seen in today’s urge to improve and over-educate. Students seem to run between “TED talks” and start-up conferences. Even health and, less surprisingly, sexuality, are parts of the injunction to enjoy. We see this on social media platforms as we force ourselves to display to others that we are living joyful lives by documenting daily pleasures, whether they are our healthy and nutritious breakfasts or our weekly workout routines. Tinder allows us to skip the volatility of relationships and the time to gain familiarity in order to exchange sexual partners as we please; on Twitter, we force ourselves to display our intellectual capacities in 140 characters or less.
The concept of forced enjoyment is of utmost importance in medicine. A patient unable to enjoy common activities is diagnosed with anhedonia. Additional symptoms such as insomnia, lack of appetite and inability to concentrate “force” doctors to diagnose the patient with major depressive disorder. Medication is used as a chemical restraint and leads to the revitalization of patients re-giving the ‘sick’ their ability to enjoy. This is a troubling pattern as it categorizes not enjoying every moment of life as abnormal. Zizek stresses the need to rid the injunction to enjoy. Doctors should approach the patient’s issue from a humanistic perspective and ask about the individual’s unique illness and question why it is manifesting currently.
The second philosopher was a Frenchman named Gilles Deleuze. He addressed a similar idea on a social level. In his essay “Postscript on the Societies of Control,” he proclaimed a new era of power within society. In order to understand him, we need to look at the idea of a French philosopher from an earlier era named Michel Foucault. He believed societies exercised power through discipline. Citizens would get caught in an unavoidable circle of institutions, thus starting over and over again by moving from one institution to the next. The institutions’ tasks were simple: to allow and forbid certain behavior by surveillance and subsequent punishment.
For Deleuze, the nineties brought a shift. In his society of control, power would not be practiced by institutions anymore; instead, it became an inherent and automatic process within the system. The subjects are caught in this process by constant self-improvement, life-long learning or promotion of their professions. Due to the these pressures, there would be no need to exercise discipline anymore.
Control plays a part in medicine too. Currently, smartphones track our step counts and locations. They alert us to improve our health and physique. Even though the JNC-8 is more lenient with its definition of hypertension, the American College of Cardiology has become stricter by recently changing the definition for the hypertension threshold from ≥140 mmHg systolic blood pressure or ≥ 90 mmHg diastolic blood pressure to 130-139/80-89 mmHg, respectively. The inherent control is not the change of the definition, but rather the underlying ideology to improve health. Improving health is more than just increased blood pressure in need of anti-hypertensive drugs. In order to improve health, we must tackle illness by finding the social, personal, and, definitely, biological causes of it.
Deleuze discusses a new medicine, one “without doctors and patients,” that focuses on the epidemiology of risk groups. In this scenario, the patient is assigned a digit that corresponds to a body of possible morbidities. Bob, the hypertensive with diabetes, is in risk group X, while Susan, who has a lack of drive, is in risk group Y.
This new medicine of control forces us to address how our society deals with people who cannot enjoy or improve themselves due to chronic diseases, disability or other biopsychosocial burdens. Essentially, this inherent control and injunction to enjoy robs us of the ability to question the definition of a life that is worth living. During our quest for constant self-improvement and pleasure, we lose track of issues that are essential to who we are as humans. A life worth living is one that contains a volatile range of emotion.
Is not a good life one which allows maturation and forces us to face the anxiety and self-esteem crises from which we hide? A society must, at its core, give us an opportunity to relax and be satisfied with the reality despite lack of improvement.
We as medical students and doctors see suffering, moaning and pain on a daily basis. We need to recall that life contains more than joy and the vague term of happiness. Unpleasant emotions are natural parts of life. In order to live a good life, we need not enjoy every moment.