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Microsoft word - in control of what.doc

Ivanovas & Simon Control over what?
Ivanovas G and Simon FB
Conference of the International Society for the Systems Siences (ISSS),
Heraklion, Crete 2003
ABSTRACTComplex situations are difficult to overlook. Not to get lost, we need clear concepts andstrategies. Reading the titles of the conference the question arises who is in control of what. Inthe definition what we suppose to control lies already the strategy how we want to control.
But the definition of the territory of control also implies as well what is out of control.
The logical Calculus of Spencer-Brown has proved to be helpful to judge complex situations.
When it was introduce in the sixties of the last century it was especially praised by Heinz vonFoerster and was applied by many systemic thinkers as Francisco Varela, Niklas Luhmannand Fritz B. Simon.
In this paper we apply the calculus of Spencer-Brown to the concept of modern medicine. Weshow that a complex problem can be formally reduced to simple logic forms. In using theselogical forms we may exactly define limitations of a linear concept and where and to whatpurpose a systemic approach is necessary.
Keywords: Calculus of Spencer-Brown, reductionism, mechanisms in medicine, definition ofhealth, side effects The calculus of Spencer-Brown
The calculus of Spencer-Brown has the advantage, compared to other forms of logic, that itcan formalise complex phenomena in a simple way. Therefore it is especially useful indescribing systemic relationships. The logical principles here presented can be applied to anycomplex situation. As a model we use medical thinking. We demonstrate how our definitionscreate a world of perception with its limitations inherent in the definitions. Understandingthese limitations helps to avoid undesirable trends and the waste of resources.
The calculus of Spencer-Brown (Spencer-Brown, 1969) is plain. It is based on the assumptionthat every perception has two fundamental properties: distinction and indication.
In gestalt-theory these principles have been generally established. To perceive an object,someone has to distinguish a figure from a ground, thus creating a gestalt. Whatever weperceive is ‘figure’, whatever is not part of the object is ‘ground’. The same is true for everydefinition, for every model, for every concept. A definition is the distinction of the definedand the not defined.
The mathematical sign for a distinction is: This mark or token distinguishes a marked state inside the rectangle (definition, model, objector whatever) from an unmarked state outside. It is as simple as it is fundamental that we can Ivanovas & Simon Control over what?
only make statements in defined (marked) states. Mathematically the sign means: Go in themarked state.
This procedure of going from an unmarked state to a marked state is called crossing. Thecalculus allows now only two operations. One is the repetition formulated in the ‘law ofcalling’: The value of a call made again is the value of the call. That means, if you callsomeone twice you call the same person. In the novel Sinuhe the Egyptian Mikas Waltaridescribes a women, Nefer, who was so beautiful that everybody had to say her name threetimes: Nefernefernefer. According to the law of calling this has the same logical value as thename called once. Or if we want to explain where a dog’s muck is, we can do this by sayingthat it is in the left corner of the garden, we might give the exact geographic position or wemight define it by it’s smell, but it remains the same dog’s muck. Also Any Warhol worked alot with this principle.
The formal sign for calling again is The other allowed operation is the change that can only consist in leaving (crossing again) themarked state. This is formulated in the ‘law of crossing’: The value of a crossing made againis not the value of the crossing.
This again is very simple. If we state, e.g. where John is, this statement is only true for acertain space. We can define (perceive, mark) a house and look whether John is inside. If he isinside he had crossed from the unmarked state (every place that is not the house) to themarked state (the house). If he now leaves the house, he crosses again in the unmarked stateand we can make no statement any more about John. We only now that he is in the ‘not-house’. With the re-crossing vanishes the value of our definition. Not only it is impossible tomake a statement about John, but also the house vanishes so to speak, because the house wasonly of interest within the context of John.
The formal sign for crossing again is: These two principles allow us already to build up a complex logical structure that leads to farreaching conclusions. Although the calculus of Spencer-Brown has as well a strategy to dealwith recursive functions, this will not be used in our approach.
Definitions in medicine
In medicine the principles of crossing and crossing again are obvious: If someone gets ill, heis crossing in the defined state of disease and he becomes a patient. If the patient gets wellagain this has the value of crossing again. He becomes a normal human being about whom itcan be said only that he is not a patient. As a result also the disease vanishes, because therecan be no disease without a patient. Disease is, so to say, a logical placeholder that allows usto examine the status of a person.
If we now try to investigate the structure of this process, we have to start with an undefinedstate, which is split up with a so-called ‘first distinction’. Our first distinction is the separationof health and disease. As the first distinction can only separate a defined from an undefinedspace, we have to check first what is marked by our first distinction. The current medicalapproach does not speak of disease in general but only of certain, defined diseases. A look in Ivanovas & Simon Control over what?
a medical textbook is sufficient proof. Even in preventive medicine there is no generalprevention but a prevention of certain diseases. Thus This means that statements about health are not valid in our current medical approach,because health is the undefined (unmarked) state. There are no epistemological means toobserve health. It is the ground that provides room for the figure of the specific disease. Thispractice is in opposition to the WHO definition of health which says that disease is theabsence of health. As a first step we might state that the definition of the WHO is wrong, or inmilder form, that it is not in line with our current medical thinking. Statements about healthare often paradox and must be so, because they are generated with a not suitable logic (Simon,1999).
Specific interventions
Formalising therapeutic interventions, we have to take into account, that they are based on amodel using a linear idea of cause and effect. A therapy is always ‘specific’ to a previouslydefined disease and to the according causal relationship. As an organism has other ways ofgetting well, we call these other ways ‘unspecific’. Already the choice of words correspondsto the suggested formalisation Specific therapy is the consequence of the specific disease and both are the result of how weobserve symptoms. Healing is a change in the observed symptoms. Change means, asdemonstrated before, that a value is or is not in a certain defined state. Therefore: About the non-specific (not according to the model) no statement is formally allowed. Thisprovides however some severe problems in the judgement of therapies.
Effectiveness and Control
To prove the effectiveness of a therapy we normally use the so called double-blind test. It is acontrolled therapy where one group of patients is given the real remedy and the control groupis given a so called placebo, a substance that looks like the remedy but has no activesubstance. As neither the patient nor the administrating person knows whether it is a so calledverum or placebo, both are blind. This test, however, is less sound than we usually expect.
Firstly, it is not capable of discovering rare and serious side effects or side effects that occuronly under certain circumstances. Contergan and Baycol are famous examples of this. On theother hand, many of the ‘paradox reactions’ of a therapy, i.e. effects that don’t correspond tothe model, were found only in extensive studies. However, these studies are carried out only Ivanovas & Simon Control over what?
for few substances. Thus, the CAST-study (Echt, 1991) found that antiarrhythmic drugs leadto more deaths and NaF in the therapy of osteoporosis lead to more hip-fractures, at least at acertain dosage (Riggs, 1990). This was discovered long after the substances had been on themarket and had proved their effectiveness in various double-blind tests. Less drastic errorscan not be detected because they slip through the large meshes of statistic measurement. Thisis due to the fact that we have no means to observe unexpected events except statisticevidence.
But in the control of efficacy there is also a change in the strategy of observation. From ananalytical approach we switch to a phenomenological. At this interface there is anepistemological gap. Normally we do not realise this jump over the abyss, because we areused to cover it with technical terms. When it can not be covered and the observations are notaccording to the model anymore, an ‘anomaly of science’ (Kuhn, 1962) arises. In medicaltherapy one of these irregularities is the so called placebo effect.
People recover after receiving medicine that contains no active substance (i.e. an injection ofphysiological salt solution) or an active substance that is not good for the disease (antibioticsin virus infection). This is not foreseen by the model and needs explanation. But actually thereis no idea how to deal with this phenomenon. It is called placebo effect and every medicalstudent knows what it is or thinks (s)he knows. But there is hardly anything as enigmatic inmedicine as the placebo effect. Although there exists a kind of ‘naïve realism’ in the use ofthe term placebo, where everybody with a wink seems to understand what is talked about.
However: „Probably the biggest enemy of understanding the placebo is commonsense”(Harrington, 1997, p 216). As usual in these situations, there is a call for more researchon this effect and there even exists an institute to investigate it (UCLA NeuropsychiatricInstitute
Mostly the placebo effect is called ‘psychic’ or ‘psychosomatic’. But that does not stand up toresearch. A higher suggestibility does not correspond to the responsiveness to placebos, asthis hypothesis would suggest. Furthermore, the reactions to placebo follow a different patternthan reactions on suggestion and hypnosis (Gauler, 1997, pp 14-15). Nor is any other modeladequate to describe the placebo phenomenon (Gauler, 1997, pp 13-28; Harrington, 1997, p.
What makes the placebo effect so exciting in logical terms is that every attempt fails to pin itdown or, in other words, to observe it in a ‘marked state’. Placebo research is the interestingand paradox question whether an ineffective drug is effective or not. Correspondingly, theresults of placebo research are confusing: A meta-analysis of placebo-controlled studies, which also included a untreated group, showed that placebos are ineffective and not superior to non-treatment. Theplacebo group had no better effects than the non-treated (Spiegel et al, 2001).
A meta-analysis of anti-depressive drugs showed that a verum is hardly more effective than a placebo, but both are more effective than non-treatment. (Kirsch &Sapirstein, 1998).
Ivanovas & Simon Control over what?
This impossibility to define the placebo effect has led some scientists to despair. “In thehealing process the placebo effect is … all that what is beyond scientific explanation”(Gauler, 1997, p.42). This is true if we define ‘scientific’ as the reductionist approach.
But we can see the placebo effect also as an ‘anomaly of normal science’, born out of theincompatibility of the strategy of observation and the observed process. Or as Huntingtonsays: „Placebos are the ghosts that haunt our house of biomedical objectivity, the creaturesthat rise up from the dark and expose the paradoxes and fissures in our self-created definitionsof the real and active factors in treatment.” (Harrington, 1997, p.1). This can easily be provedin formalising therapy models.
The substance to be investigated is the verum (V), the therapeutic model is the specifictherapy. All interventions that are not specific according to the model are called placebo (P).
As people are able to recover without being concerned about V and P we call thisspontaneous recovery (S). In some definitions is P = P + S.
A therapy, to be serious, has to fulfil V > P.
If we assume a linear process, we can find a lot of combinations, depending on whether V, Pand S use the same therapeutic principles, work additively, i.e. complement each or impedeeach other. Indications exist for every assumption. Thus, it could be proved that the opiumand endorphin antagonist Naloxone is able to block placebo induced analgesia (Gauler, 1997,p. 27). Stoessel found in Parkinson’s disease that placebo induced about the same secretion ofDopamine in the brain as the verum does (de la Fuente-Fernández, 2001). Similarly Petrovicfound the same neuronal patterns in placebo- and opoid-analgesia (Petrovic, 2002), whereasLeuchter found that anti-depressive drugs induce a different neuronal pattern to the placebo(Leuchter, 2002).
Theoretically, V + P + S could be added to create an extraordinary healing process. Naturallythe version P + S – V = 0 (the verum impedes self-healing abilities of the body) is alsothinkable, but so indeed is every other combination.
The question is whether the human organism is acting according to these additions andsubtractions. Indeed it would be strange if it were so. General System Theory is providing amuch better model to describe and understand V, P and S (von Bertalanffy, 1969, p. 40-41)The term equifinality describes the reaction of an open system which tries to achieve a givenset point or goal independent of partial functions. If we see health as equilibrium,appropriately balanced to the demands of environment, then the organism in disease(according to equifinality) will use quite different mechanisms to reach the set point again. Itwould be quite normal to see these different mechanisms interfere with each other,corresponding to their starting point. An organism in situation A1 will ‘produce’ a different P and S and will react differently to V to one in situation A2. It is understandable that disease X could have other mechanisms for self-healing than disease Y, and that this self-healing isdifferent with each V.
Again the calculus of Spencer-Brown helps us to make clear statements about specific andnon specific treatments, solving all the problems constructed before. If we want to examinethe relationship of specific and non specific effects, we come to the following form: This ‘effect/side-effect’ constellation fits exactly the most widely accepted definition of theplacebo effect by A. Shapiro, the father of placebo research: “We define the placebo effect asthe non-specific, psychological, or psycho-physiological therapeutic effect produced by aplacebo, or the effect of spontaneous improvement attributed to the placebo” (Harrington,1997, p. 12).
Placebo is the logical consequence of the specific verum and the placebo effect is defined asthe sum of undefined effects. The correct form is Ivanovas & Simon Control over what?
As the placebo effect is always in the unmarked state there is nothing to find out about it. Ageneral statement on the placebo effect is therefore a logical contradiction and this explainsexactly the paradoxes in placebo research. Of course there are results in the different studiesabout placebos and their effect. But when we look at the proceedings more formally andinvestigate the logical structure of double-blind test the basic problem of the specific(reductionist) approach occurs here that does not exist in the systemic approach. In theobservation there is only effect or not. Every medicament is a mixture of a specific (p) and anon-specific (r) effect. The effect of the verum is phenomenological pr and not p r, aspostulated. And of cause also the placebo has a specific effect (q), which can be neglected andan unspecific effect (r). So placebo effect is qr .
The double-blind test (outer token) measures the specific effect of verum/placebo-effect (pr)and the specific effect of placebo/placebo effect (qr). It can only measure the specific effect,because disease is in its mechanism defined as specific.
The logical form of the double-blind test is According to the law of crossing we apply the formula of ‘transposition’(Spencer-Brown,1969, p. 28) Thus the placebo effect is again in the unmarked state. This is proof of a correct logicalprocedure because the placebo effect has formerly been defined as unspecific (unmarked).
Echt, D., Liebson, P., Mitchell, L., Peters, R., Obias-Manno, D., Barker, A., Arensberg, D.,
Baker, A., Friedman, L., Greene, H., and et al. (1991): Mortality and morbidity inpatients receiving encainide, flecainide, or placebo. The Cardiac ArrhythmiaSuppression Trial, New England Journal of Medicine, March 21, 1991, No. 12, Vol324, pp. 781-788 de la Fuente-Fernández, R., Ruth, T., Sossi, V., Schulzer, M., Calne, D. and A. Jon Stoessl (2001): Expectation and Dopamine Release: Mechanism of the Placebo Effect in Parkinson's Disease,Science 2001 August 10; 293: 1164-1166 Gauler, T.C. (1997) Placebo – Ein wirksames und ungefährliches Medikament? Urban und Harrington, A. ed. (1997): The Placebo Effect, Harvard Univ. Press, Cambridge, Mass.
Ivanovas, G (2001): Doppelblind bei alternativen Heilverfahren, Deutsches Ärzteblatt 13/2001, pp.
Kirsch, I. & Sapirstein, G. (1998): Listening to Prozac but Hearing Placebo: A Meta-Analysis of Antidepressant Medication, Prevention & Treatment, Volume 1, Article 0002a, posted June26, Kollath, W. (1983): Der Vollwert der Nahrung, Haug, HeidelbergKuhn, T. (1962): The Structure of Scientific Revolution, University of Chicago, Chicago Ivanovas & Simon Control over what?
Leuchter, A., Cook, I., Witte, E., Morgan, M. and Abrams, M (2002): Changes in Brain Function of Depressed Subjects During Treatment With Placebo, Am J Psychiatry 159 , January 2002, pp122-129 Petrovic, P. (2002): Placebo and Opioid Analgesia--Imaging a Shared Neuronal Network, Science, Vol. 295, March 1, Issue 5560, pp. 1737-1740 Riggs, B., Hodgson, S., O'Fallon, W., Chao, E., Wahner, H., Muhs, J., Cedel, S. and Melton, L.
(1990): Effect of fluoride treatment on the fracture rate in postmenopausal women withosteoporosis, New England Journal of Medicine 12/90, Vol 322, March 22, pp. 802-809 Simon, F.B. (1999): The other side of illness, in Problems of Form (D. Baecker, ed.), Stanford Univ.
Spencer-Brown, G. (1969): Laws of Form, Allen&Unwin, London 1969Spiegel D., Kraemer H., Carlson R. W., McDonald C. J., Miller F. G., Kaptchuk T. J., Einarson T. E., Hemels M., Stolk P., Lilford R. J., Braunholtz D. A., Kupers R., Shrier I., DiNubile M. J.,Beldoch M., Hróbjartsson A., Gøtzsche P. C. (2001): Is the Placebo Powerless? NewEngland Journal of Medicine 2001; 345:1276-1279, Oct 25 Von Bertalanffy, L. (1969): General System Theory, Braziller, New York


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