L'avenir de la vie (Dr Michel Salomon, 1980)

“Ein Wunderkind”, the Germans would say, a child prodigy. At less than forty years of age, Jacques Attali is an internationally renowned economist, a teacher, a popular political advisor to the Socialist Party and a versatile writer, author not only of theoretical works on his discipline, but also of essays in fields as varied as politics, music and, recently, medicine. The book he published in the autumn of 1979, “L’Ordre Cannibale ou Pouvoir et Déclin de la Médecine” (The Cannibal Order or the Power and Decline of Medicine), reopened the debate in France, not only on the validity of the therapeutic act but on all the existential problems, from birth to death, which underlie the organisation of the health care system in the West.

What makes Attali tick?

For those who are his friends, so much energy deployed in so many directions at once is disconcerting. For his enemies – and he has many, not so much because of his likeable, engaging personality as because of his political options – this gifted man is suspect. Rooted in a land of reason, of measure, of the “middle ground” – the middle of what exactly? The French establishment has always been suspicious of intellectuals who trample on its “French-style” gardens…

Jacques Attali is undoubtedly disturbing, with his excesses, his outrages, his permanent and feverish questioning. But in these times of crisis, don’t we need to be more “worried” than reassured?

MICHEL SALOMON – Why is an economist so passionately interested in medicine, in health…

JACQUES ATTALI – In studying the general economic problems of Western society, I have noticed that health costs are one of the essential factors in the economic crisis. The production of consumers and their maintenance is expensive, even more expensive than the production of goods themselves. People are produced by services they render to each other, especially in the field of health, whose economic productivity is not increasing very fast. “The productivity of machine production is increasing faster than the relative productivity of consumer production. This contradiction will be overcome by a transformation of the health and education system towards their commodification and industrialisation. Anyone who analyses economic history realises that our society is increasingly transforming craft activities into industrial activities and that a growing number of services rendered by people to others are increasingly becoming objects that are produced in machines.

The meeting of these two questions leads to the question: can medicine also be produced by machines that would replace the activity of the doctor?

M.S. – This question seems a bit academic, theoretical…

J.A. – Certainly, but it reflects the current crisis. If medicine, like education, were to be mass-produced, the economic crisis would be solved. It is a bit like the astronomer who says: “If my reasoning is correct, there is a star there…”. “If this reasoning is correct and if black society is coherent, the logic leads to the following: as other functions were eaten up in earlier phases of the crisis by the industrial apparatus, medicine becomes a mass-produced activity, which leads to the metaphor.

The latter means that the doctor is largely replaced by prostheses whose role is to recover the function of the body, to restore it or to substitute it. If the prosthesis attempts to do the same thing, it does so in the same way as the body’s organs do, and thus becomes a copy of body organs or body functions. Such objects would therefore be prostheses for consumption. In economic language, the metaphor is clear: it is that of cannibalism. We consume the body. So from the metaphor (and I have always thought that it was the source of knowledge), I asked myself two questions:

Is cannibalism close to a therapy?

Is there a kind of invariant in the different social structures, which would make an axiomatized cannibalism, freed from the way it was lived, and reduced to operators in the mathematical sense, be found in the therapeutic approach?

Firstly, cannibalism seems to be largely explainable as a therapeutic, foundational strategy. Secondly, it seems that all healing strategies, in relation to illness, contain a series of operations carried out by the body itself, but also by cannibalism, and that we find in all these strategies: selecting the signs to be observed, monitoring them to see if they are well or not, denouncing what will break the order of these signs, what we call Evil; negotiating with Evil, separating Evil. All healing systems have employed these same operations: selection of signs, denunciation of evil, surveillance, negotiation, separation. These different operations are also part of a political strategy: selecting signs to observe, monitoring them to see if everything is going well, denouncing the evil, the scapegoat, the enemy, and removing it. There are very deep connections between the strategy towards individual evil and the strategy towards social evil. This is what led me to think, basically, that the distinction between social evil and individual evil was not a very clear distinction. These various fundamental operations were applied in different historical periods, on different conceptions that one could have of illness, of evil, of power, of death, of life, and therefore of the one who must fulfil the function of designating evil. In other words, there are the same operations, the same roles, but it is not the same actors who play the roles. And the play is not performed at the same time.
 

M.S. – From there to founding a theory based on historical or mythical cannibalism… Your essay has upset and shocked not only doctors but also the sick people that we all potentially are, in short, public opinion…

J.A. – This essay is a triple attempt:
-Firstly, an attempt to tell an economic history of evil, the history of relationships with illness.
-Secondly, to show that there are, in a way, four dominant periods and therefore three major crises between which the system shifts are structured and that each shift does not only affect the healer, but also the very conception of life, death and illness.
-Thirdly, and finally, to show that these shifts concern the signs and not the strategy, which remains that of cannibalism, and that in fact, we start from cannibalism and return to it. In short, we can interpret the whole of industrial history as a machine for translating the founding cannibalism, the first relationship to evil, where men eat men, into industrial cannibalism, where men become commodities that eat commodities. Industrial society would function like a dictionary with different stages in the translation: there are intermediate languages, so to speak, four major languages. There is the fundamental order, the cannibal order. This is where the first gods that appear are cannibals and in the myths that follow, historically, the cannibal gods eat each other and then it becomes awful for the gods to be cannibals.

In all the myths I’ve studied, in different civilizations religion serves to sort of destroy cannibalism. For cannibalism, the evil is the souls of the dead. If I want to separate the souls of the dead from the dead, I have to eat the bodies. Because the best way to separate the dead from their souls is to eat the bodies. So what is fundamental about cannibal consumption is that it is separation. That’s what I was getting at: consumption is separation. Cannibalism is a formidable therapeutic force of power. So why does cannibalism no longer work? Well, because from the moment (we can see this in the myths – and here I’m giving an interpretation of both Girard’s work on violence and Freud’s work on “Totem and Taboo”, in which he sees the totem and the totemic meal as founders, and the totemic meal disappearing into sexuality) when I say “eating the dead” allows me to live, then… I’m going to find some to eat, so cannibalism is healing, but at the same time, it’s a producer of violence. And this is how I try to interpret the passage to sexual prohibitions, always the same as cannibalistic prohibitions. Because it is obvious that if I kill my father, or my mother, or my children, I will prevent the reproduction of the group. And yet they are the ones who are easiest to kill because they live next to me. Sexual prohibitions are secondary to food prohibitions. Then we ritualise, we stage cannibalism in a religious way. In a way, we delegate, we represent, we stage. Religious civilisation is a staging of cannibalism. The signs we observe are those of the gods. Disease is possession by the gods. The only diseases that can be observed and cured are those of possession. Finally, healing is the expulsion of the evil, the evil which in this case is the Evil One, that is, the gods. The main healer is the priest. There are always two healers at all times. There is the denouncer of evil and the separator, who will later be known as the physician and the surgeon. The denouncer of evil is the priest, and the separator is the practitioner.

I have tried to show, on the one hand, that Christian ritualisation is fundamentally cannibal. The remains of Luke on ‘bread and wine’, which are the ‘Body and Blood of Christ’, and which, if eaten, give life, are obviously cannibal texts, therapeutic texts; there is a medical, and at the same time cannibal, reading of these books which is striking.

I then try to tell the story of the Church’s relationship with healing, and to see little by little, probably from the 12th or 13th century, that a new system of signs appears. We no longer observe only the diseases coming from the gods, but also the diseases coming from the body of men. Why did this happen? Because the economy starts to become organised. The dominant diseases are epidemics that begin to circulate like men and goods. The bodies of poor men carry disease and there is a total unity between poverty (which did not exist before because almost everyone was a slave or lord) and disease. Being poor or sick meant the same thing from the 13th to the 19th century. So the strategy towards the poor in politics and the strategy towards the sick are not different. When you are poor, you become sick, when you are sick, you become poor. Illness and poverty do not yet exist. What does exist is being poor and sick, and, the poor or sick being designated, the right strategy is to separate them, to contain them, not to cure them but to destroy them: in French texts, this has been called enfermer – enfermement in the theses of Foucault. It is locked up in many ways: quarantine, the lazaretto, the hospital, and in England the workhouse. The law on the poor and charity are not ways of helping people but of designating them as such and containing them.

M. S. – The policeman becomes the therapist instead of the priest.

J. A. – That’s it. Religion withdraws and takes power elsewhere because it cannot take on the power of healing any longer. There are, of course, already doctors, but they only play a consoling role and, as proof of this, the political authorities, very astutely, still do not recognise doctors’ diplomas. The political authorities consider that their main therapist is the policeman and not the doctor. Moreover, in Europe, at the time, there was only one doctor per 100,000 inhabitants.

But I come to the third period when it is no longer possible to lock up the poor because they are too numerous. Instead, they must be maintained because they become workers. They cease to be bodies and become machines. And the signs we see are those of machines. The disease, the illness, constitutes the breakdown. Clinical language isolates and objectifies evil even more. Evil is designated, separated and expelled.

Throughout the nineteenth century, with the new surveillance that is hygiene, the new reparation, the new separation between doctor and surgeon, we see the policeman and the priest fade away behind the doctor.

M.S. – And today, it’s the doctor’s turn to fall into the trap.
 

J.A. – Today, the crisis is threefold. On the one hand, as in the previous period, the system can no longer ensure its functioning on its own. Today, in a way, medicine is largely incapable of treating all diseases because the costs are becoming too high.

On the other hand, there is a loss of credibility of the doctor. People have much more confidence in quantified data than in the doctor.

Finally, diseases or forms of behaviour are appearing which are no longer answerable to classical medicine. These three characteristics lead to a kind of natural continuum from clinical medicine to prosthetics, and I have tried to distinguish three interrelated phases in this transformation.

In the first phase, the system tries to last by keeping its financial costs under control. But this desire leads to the need to monitor behaviour and therefore to define health and activity standards to which the individual must submit. This is how the notion of a life profile that is economical in terms of health expenditure came about.

From then on, we move on to the second phase, which is that of the self-denunciation of evil thanks to the tools of self-control of behaviour. The individual can thus conform to the life profile norm and become autonomous in relation to his or her illness.

The main criterion of the behaviour was, in the first order, to give meaning to death, in the second order, to contain death, in the third order, to increase life expectancy, in the fourth order, the one we are living, it is the search for a life profile that is economical in terms of health expenditure. The third phase consists of the appearance of prostheses that allow us to designate the disease in an industrial way. Thus, for example, electronic drugs such as the pill coupled to a micro-computer make it possible to release substances, which are elements of regulation, into the body at regular intervals.
 

M.S. – In short, health, with the appearance of these electronic prostheses, will be the new engine of industrial expansion…

J.A. – Yes, in conclusion, all the traditional concepts disappear: production, consumption disappear, life and death disappear because the prosthesis makes the mon a momentary blur…

I believe that the important thing in life will no longer be to work but to be in a situation of consumption, to be a consumer among other consumption machines. The dominant social science up to now has been the science of machines. Marx is a clinician because he points to the evil, the capitalist class, and eliminates it. He says, in a way, the same thing as Pasteur, The great dominant social science will be the science of codes, computer science and then genetics. This book is also a book on codes because I try to show that there are successive codes: the religious code, the police code, the thermodynamic code and today the informational code and what is called socio-biology. This theoretical discourse is only useful if the future does not happen: we will only avoid being cannibals if we stop becoming cannibals. I believe that the essential thing for a theory to be true is not that it be refutable but that it be reerutable. The true is not the refutable, but the refuted.
 

M.S. – Does your thesis lead to a concrete reflection on medicine, even in the long term; are these the beginnings of a concrete reflection by a politician and an economist on the organisation of medicine?

J.A. – I don’t know. For the moment, I don’t want to ask myself this question. I think that the first thing that I wanted to show, only this, is that healing is a process in full transformation towards a model of organisation that has nothing to do with the current one, and that the choice is between three types of attitude: either to keep medicine as it was in the past, or to accept the evolution and make it the best possible, with greater equality of access to prostheses. or a third evolution in which the return to evil is thought of in a new way, which is neither that of the past, nor that of the future of the cannibal system; it would be an altitude close to the acceptance of death, so as to make people more aware that the urgent thing is not to forget, nor to delay, nor to wait for death, but on the contrary to want life to be as free as possible. So I think that, little by little, we will become polarised around these three types of solutions and I want to show that, in my opinion, the last one is truly human.

M.S. – This is social utopia; it’s sometimes dangerous to be utopian, —

J.A. – Utopia can have two different characteristics, depending on whether we speak of utopia as an absolute dream, in which case the dream is a dream of eternity, or whether we refer to the etymology of the word, i.e. to what has never taken place, and we then try to see what type of utopia is plausible, but I think that if we want to understand the problem of health, we have to realise that there are plausible utopias. The future is necessarily a utopia, and it is very important to understand that it is not dangerous, because to bet on utopia means to accept the idea that the future has nothing to do with the prolongation of current trends. I would even say that all futures are possible except one, which would be a continuation of the current situation.

M.S. – Is the future this particular prosthesis that is the medicine of the future – and of the present – that helps man to better bear his condition? ‘1

J.A. – I find this fascination with anti-hunger drugs, with everything that can eliminate hunger, frightening, but as a commodity and not as a way of life. We are trying to provide the means to make anxiety tolerable and not to create the functions to stop being anxious. It would be possible to reconcile parliamentary democracy with totalitarianism, since it would be enough to maintain all the formal rules of parliamentary democracy but at the same time to generalise the use of these products so that totalitarianism would be daily,

M.S. – Does this seem conceivable, an Orwellian “1984” based on a pharmacology of behaviour?

J.A. – I don’t believe in Orwellianism, because it’s a form of technical totalitarianism with a visible and centralised “Big Brother”. I believe rather in implicit totalitarianism with an invisible and decentralised “Big Brother”. These machines for monitoring our health, which we could have for our own good, will enslave us for our own good. In a way, we will be subjected to gentle and permanent conditioning…

M.S. – How do you see the man of the XXI” century?

J.A. – I believe that we must make a clear distinction between two kinds of man in the 21st century: the man of the 21st century in rich countries and the man of the 21st century in poor countries. The first will certainly be a man who is much more anxious than he is today, but who will find his answer to the pain of living in a passive tutelage, in painkillers and anti-anxiety machines, in drugs, and who will try at all costs to live a kind of commercial form of conviviality. But apart from that, I’m convinced that the immediate majority, who will have knowledge of these machines and the lifestyle of the rich but who will not have access to them, will be extraordinarily aggressive and violent. It is from this distortion that the great chaos will be born, which could be translated either by racial wars, conquests, or by the immigration of millions of people into our countries who will want to share our way of life.

M.S. – Do you believe that genetic engineering is “one of the dice of our future?"

J.A. – I believe that in the next twenty years genetic engineering will be as commonplace, as well-known and as present in everyday life as the internal combustion engine is today. In fact, the same type of parallel can be drawn.

With the internal combustion engine, we could make two choices: either to favour public transport and make people’s lives easier, or to produce cars, tools of aggressiveness, consumption, individualisation, solitude, storage, desire, rivalry… We chose the second solution. I believe that with genetic engineering we have the same type of choice and I believe that we will also choose, unfortunately, the second solution. In other words, with genetic engineering we could gradually create the conditions for humanity to assume itself freely, but collectively, or else create the conditions for a new commodity, genetic this time, which would be made up of copies of humans sold to humans, chimeras or hybrids used as slaves, robots, means of work…

M.S. – Is it possible and desirable to live 120 years?

J.A. – Medically, I don’t know. I’ve always been told that it was possible. Is it desirable? I would answer in several stages. First of all, I believe that in the logic of the industrial system in which we find ourselves, the extension of life expectancy is no longer an objective desired by the logic of power. Because as long as it was a question of extending life expectancy in order to reach the maximum profitability threshold of the human machine, in terms of work, it was perfect.

But as soon as you go beyond 60/65, people live longer than they produce and they cost society dearly.

Hence I believe that in the very logic of industrial society, the objective will no longer be to extend life expectancy, but to ensure that within a given life span, people live as well as possible, but in such a way that health expenditure will be as low as possible in terms of costs for the community. A new criterion of life expectancy then appears: that of the value of a health care system, which is not a function of the increase in life expectancy but of the number of years without illness and particularly without hospitalisation. Indeed, from the point of view of society, it is much better for the human machine to come to an abrupt halt than for it to deteriorate gradually.

This is perfectly clear if we remember that two thirds of health expenditure is concentrated on the last words of life. Similarly, cynicism aside, health expenditure would not reach a third of the current level (175 billion francs in 1979) if people all died suddenly in car accidents. Thus, we must recognise that the logic no longer lies in increasing life expectancy but in increasing the duration of life without illness. However, I think that increasing life expectancy remains a fantasy that corresponds to two objectives: the first is that of the men of power. The increasingly totalitarian and directive societies in which we find ourselves tend to be led by “old” men, to become gerontocracies. The second reason is the possibility for capitalist society to make old age economically profitable simply by making old people solvent. It is currently a “market”, but it is not solvent.

This is entirely consistent with the view that man is no longer important as a worker but as a consumer (because he is replaced by machines in his work). So we could accept the idea of longer life expectancy on condition that old people are made solvent and a market is created. It is easy to see how big pharmaceutical companies behave today in relatively egalitarian countries where at least the method of financing retirement is correct: they favour geriatrics, to the detriment of other areas of research such as tropical diseases.

It is therefore a problem of retirement technology that determines the acceptability of life expectancy.

As a socialist, I am objectively opposed to extending life because it is an illusion, a false problem. I believe that posing this type of problem allows us to avoid more essential questions such as the liberation of time actually lived in the present life. What is the point of living to 100 years if we gain 20 years of dictatorship?

M.S. – The world to come, whether “liberal” or “socialist”, will need a “biological” morality, to create an ethic of cloning or euthanasia for example.

J.A. – Euthanasia will be one of the essential instruments of our future societies in all cases. In a socialist logic, to begin with, the problem is as follows: socialist logic is freedom and fundamental freedom is suicide; consequently, the right to direct or indirect suicide is an absolute value in this type of society. In a capitalist society, killing machines, prostheses that will make it possible to eliminate life when it is too unbearable or economically too costly, will come into being and will be common practice. I therefore believe that euthanasia, whether it is a value of freedom or a commodity, will be one of the rules of future society.

M.S. – Won’t the men of tomorrow be conditioned by psychotropic drugs and subjected to psychological manipulation? How can we guard against this?

J.A. – The only precautions that can be taken are linked to knowledge. It is essential today to ban a very large number of drugs, to stop the proliferation of conditioning drugs; but perhaps the frontier has already been crossed…
Is television not an excessive drug?
Hasn’t alcohol always been a drug of abuse?
The worst drug is the absence of culture. People want drugs because they have no culture. Why do they seek alienation through drugs? Because they have become aware of their powerlessness to live, and this powerlessness is concretely translated into a total refusal of life.

An optimistic bet on man would be to say that if man had culture, in the sense of the tools of thought, he could escape the solutions of impotence. So, to take evil at its roots is to give man a formidable instrument of subversion and creativity.

I don’t think that banning drugs would be enough. If we don’t attack a problem at its root, we inevitably fall into the trap of the police and that’s worse.

M.S. – How will we deal with mental illness in the future?

J.A. – The problem of the evolution of mental illness medicine will be in two stages. In the first stage, there will be even more drugs, psychotropic drugs, which correspond to real progress in mental medicine over the last 30 years.

It seems to me that, in a second phase, and for economic reasons, a certain number of electronic means will be put in place, which will be either methods of pain control (bio-feed-back, etc.) or a computerised system of psychoanalytical dialogues.

The consequence of this development will be to lead to what I call the explicitation of the normal; that is to say, electronic means will make it possible to define the normal with precision and to quantify social behaviour. The latter will become economically consumable since the means and criteria for conformity to norms will exist. In the long term, when disease is overcome, the temptation to conform to the “biological normal” that conditions the functioning of an absolute social organisation will be revealed.

Medicine is indicative of the evolution of a society that is moving towards a decentralised totalitarianism. We can already see a certain conscious or unconscious desire to conform as much as possible to social norms.

M.S. – Do you see this forced normalisation governing all areas of life, including sexuality, since science today allows for the almost total dissociation of sexuality and conception?

J.A. – From an economic point of view, there are two reasons why I think we will go very far.

The first is that the production of men is not yet a market like any other. Following the logic of my general reasoning, it is impossible to see why procreation should not become an economic production like any other.

It is perfectly possible to imagine that the family or the woman is only one of the means of production of a particular object, the child.

We can, in a way, imagine “rental matrices” which are already technically possible. This idea corresponds entirely to an economic evolution in the sense that the woman or the couple will become part of the division of labour and general production. Thus it will be possible to buy children in the same way as one buys “peanuts” or a television set.

There is a second important and related reason for this new family order. If from an economic point of view, children are a commodity like any other, society also considers them as such, but for social reasons. Indeed, the survival of communities depends on a demography sufficient for its survival. If, for economic reasons, a family does not wish to have more than two children, this attitude is obviously opposed to the interests of the community! Thus, there is an absolute contradiction between the interests of the family and those of society. The only way to resolve this contradiction is to imagine that society could buy children from a family that would be paid in return. I am not thinking of family allowances, which are weak incentives. A family would agree to have many children if the state guaranteed them substantial progressive allowances on the one hand and full responsibility for the material life of each child on the other. In this scheme, the child would become a kind of bargaining chip in the relationship between the individual and the community.

What I am saying here is not a kind of complacency in the face of what seems inevitable. It is a warning. I believe that this world in preparation will be so awful that it will mean the death of man. We must therefore be prepared to resist it, and it seems to me today that the best way to do so is to understand, to accept the struggle, to avoid the worst. That’s why I push my reasoning to the limit…

M.S. – Resist what, since you are announcing an inescapable universe of prostheses?

J.A. – The prostheses that I see coming are not mechanical but are means of fighting against chronic affections linked to the phenomenon of tissue degeneration. Cellular engineering, genetic engineering and cloning are paving the way for these prostheses, which will be regenerated organs replacing failing organs.

M.S. – The increasing penetration of computers in society calls for ethical reflection. Is there not an underlying threat to human freedom?

J.A. – It is clear that the discourse on prevention, health economics and good medical practice will lead to the need for each individual to have a medical file which will be put on a magnetic tape. For epidemiological reasons, all these files will be centralised in a computer to which doctors will have access. The question arises: will the police be able to access these files? I can honestly say that Sweden now has this kind of sophisticated system and is not a dictatorship. I would add that some countries do not have these files but do have a dictatorship. Let’s create new procedures as a bulwark against new threats. Democracy has a duty to adapt to technical developments. Old constitutions confronted with new technologies can lead to totalitarian systems.

M.S. – One of the most common projections for the future is that man will be able to exercise biological control over his own body, among other things, thanks to microprocessors…

J.A. – This control already exists for the heart through ‘pacemakers’, and also for the pancreas.

It should be extended to other areas such as pain. It is planned to develop small implants in the body that can release hormones and active substances in target organs.

If the aim is to prolong life, this progress is inevitable.

M.S. – It seems that we are leaving the era of physics to enter the era of biology, close to a pan-biology. Is this your opinion?

J.A. – I believe that we are leaving a universe controlled by energy to enter the universe of information. If matter is energy, life is information. This is why the major producer of tomorrow’s society will be living matter. Thanks in particular to genetic engineering, it will produce new therapeutic weapons, food and energy.

M.S. – What is the future of the doctor and medical power?

J.A. – I would say that, in the same way that washerwomen have disappeared behind the advertising images of washing machines, doctors integrated into the industrial system will become the stooges of the biological prosthesis. The doctor we know will disappear and be replaced by a new social category living off the prosthesis industry. As with washing machines, there will be prosthesis creators, sellers, installers and repairers. What I am saying may come as a surprise, but do you know that the main companies thinking about prostheses are the big car companies, such as Renault, General Motors and Ford…

M.S. – In other words, there will no longer be any need for medical therapists because “normalisation” will be carried out by a sort of preventive medicine, whether or not it is self-managed, and in any case “controlled”. Will it not necessarily be coercive?

J.A. – The appearance on the market of individualised self-monitoring and self-controlled items will create a preventive spirit. People will adapt themselves in such a way as to conform to the criteria of normality; prevention will no longer be coercive because it will be desired by the people. But we should not lose sight of the fact that the most important thing is not technological progress, but the highest form of trade between people, which is culture. The form of society that the future will bring depends on the ability to master technical progress. Will we dominate it or will we be dominated by it? That is the question.

ROUGH TRANSLATION OF
Michel_Salomon_Future_of_Life.pdf

• This is the original Google Translate translation that will remain until I verify, although I'm pretty sure the former is proper.  —Chad

"Ein Wunderkind" would say the Germans, a child-prodigy. At less than forty years old, Jacques Attali is both an economist. . international reputation, a teacher, a much listened to political advisor of the socialist party and a writer in v ~ rs: 3ti ~ e, other theoretical works on sn dtsc1phne, but of essays noticed in fields as varied as politics, music, and recently medicine. The book he published in the fall of 1979, “L'O rdr; Cannibal e or Pouvoir et Déclin de la Médecin e ”, has revived the debate in France, not only on the validity of the therapeutic act but on all the existing problems, from birth to death, which underlie the organization of the healthcare system in the West.

What makes Attali run?
For those who are his friends, so much energy expended in so many ~ irections ~ at a time baffles them. For those who are his nem is -and he has many, less because of his amiable, endearing personality, than because of his political options -this gifted is suspect. Rooted in a land of reason, of measure? of “happy medium”, -the middle of what? -, the hexagonal establishment has always been wary of intellectuals who trample on its "French" gardens, ..
Ja cqu es Attali undoubtedly disturbs, with his excesses St.lll excesses, his constant and feverish questioning. But in these times of crisis, don't we need to be more "worried" than reassured? ...

MICHEL SALOMON. -Why is an economist interested with so much passion in medicine, health ...

JACQUES ATIALI. -I have observed by studying the general economic problems of Western society that health costs are one of the essential factors of the economic crisis. The production of consumers and their maintenance are costly, even more expensive than the production of the goods themselves. Men are produced by the services they render to each other, particularly in the field of health, the economic ductivity of which does not increase very quickly. "~ Productivity of machine production" is increasing faster than the relative productivity of consumer production. This contradiction will be removed by a transformation of the health and education system towards their marketization and industrialization. Anyone who analyzes economic history realizes that our society is increasingly transforming craft activities into industrial activities and that a growing number of services rendered by men to others are becoming more and more frequent. more objects that are produced in machines.
The meeting of these two questions leads to the question: can medicine, too, be produced by machines which will replace the activity of the doctor?

M. S. - This question seems a little academic, theoretical ...

J. A. - Certainly, but it gives an account of the current crisis. If medicine, like education, were to be mass-produced, the economic crisis would be resolved quickly. It is a bit the point of view of _l'astrono ~ e who would say: "If my reasoning is correct, there is a star...".
This reasoning is correct and if our society is coherent, the logic leads to this: as other functions have been eaten up, in the previous phases of the crisis, by the industrial apparatus, medicine becomes a serial pro. activity, which leads to the metaphor.
The latter means that the medicine is largely replaced by prostheses which are intended to recover the function of the body, to restore it or to replace it. If the prosthesis tries to do the same thing, it does it the same way the body organs do - and therefore it becomes a copy of body organs or functions of the body. Such objects would therefore be prostheses to be consumed. In economic language the metaphor is clear: it is that of cannibalism. We consume the body.
So from the metaphor (and I always thought she was
source of knowledge) I asked myself two questions: Is cannibalism close to therapy? Is there some kind of invariant in the different
social structures, which would mean that an axiomatized cannibalism, freed from the way it was experienced, and reduced to operators, in the mathematical sense, would be found in the therapeutic approach?
First, cannibalism seems to be able to be explained quite broadly as a therapeutic, founding strategy. Second, it seems that all the healing strategies, in relation to the disease contain a series of operations made by the body itself but also done by cannibalism and which we find in all these strategies: select signs that we will observe, watch them to see if they are doing well or not, denounce what will break the order of these signs, what is called Evil; to negotiate with Evil, to separate Evil. All healing systems have thus employed these same operations: selection of signs, denunciation of evil, surveillance, negotiation, separation. These different operations are also part of a political strategy: select signs to observe, monitor them to see if everything is going well, denounce the evil, the scapegoat, the enemy, and remove it. There are very deep connections between the strategy with regard to individual evil, and the strategy with regard to social evil. This is what led me to think, basically, that the distinction between social evil and individual evil was not a very clear one. These various fundamental operations apply to different historical periods, to different conceptions that one could have of disease, evil, power, death, life, and therefore of that which must fulfill the function of designation of evil, of separation. In other words, there are the same operations s, the same res, but it is not the same actors who play the res. And the play is not being played at the same time.

M. S. - From there to founding a theory on the basis of historical or mythical cannibalism ... Your essay has upset and shocked not only the doctors but also these patients that we are all in power, in short public opinion ...

J. A. -This essay is a threefold attempt: First, an attempt to tell an economic story of Evil, the history of relationships with disease.
Second, to show that there are, in a way, four dominant periods and therefore three major crises between which system shifts are structured and that each shift affects not only the healer, but also the very conception of life, death and disease.
Third, and finally, to show that these shifts concern the signs and not the strategy, which remains that of cannibalism, and that in fact, we start from cannibalism and come back to it. In short, the whole of industrial history can be interpreted as a machine for translating founding cannibalism, the first relation to evil, men eat men, in industrial cannibalism, men become commodities which eat commodities. Industrial society functions like a dictionary with different stages in the translation: there are intermediate languages, in a way, four major languages. There is the fundamental order, the cannibal order. This is where the first gods that appear are cannibals and that in the myths that follow, historically, cannibal gods eat each other, then it becomes awful for the gods to be cannibals.
In all the myths that I have studied, in different civilizations religion is used in some way to destroy cannibalism. For cannibalism, evil is the souls of the dead. If I want to separate the soul of the dead from the dead, I must eat the bodies. Because the best way to separate the dead from their souls is to eat the bodies. So what is fundamental in cannibal consumption is that it is separation. This is where I wanted to come from: consumption is separation. Cannibalism is a formidable therapeutic force of power. So why does cannibalism no longer work? Well, because from the moment (we can see it in the myths, - and I give here an interpretation both of Girard's work on violence and of Freud on "Totem and taboo", in which he sees the totem and the totemic meal as founders, and the totemic meal disappearing in sexuality) where I say "eating the dead" allows me to live, so ... I will find something to eat. So cannibalism is a healer, but at the same time it is a producer of violence. And that's how I try to interpret the passage to sexual prohibitions, always the same as the cannibal prohibitions. Because it is obvious that if I kill my father, or my mother, or my children, I will prevent the reproduction of the group. And yet they are the ones who are easiest to kill since they live next to me. Sexual prohibitions are secondary prohibitions compared to food prohibitions. Then, we ritualize, we stage cannibalism in a religious way. In a way, we delegate, we represent, we stage. The civilization religious is a staging of cannibalism. The signs we observe are those of the gods. Sickness is possession by the gods. The only diseases that can be observed and cured are those of possession. Healing, finally, is the expulsion of evil, the evil which, in this case, is the Evil One, that is to say the gods. And the main healer is the priest. There are always two healers at all times. There is the whistleblower of the evil and the separator, which will then be found under the names of doctor and surgeon. The denouncer of evil is the priest, and the separator is the practitioner.
I have tried to show, on the one hand, that Christian ritualization is fundamentally cannibalistic. Luke's texts on "bread and wine" which are "the Body and Blood of Christ", and which if eaten give life, are cannibalistic texts, obviously therapeutic; there is a medical reading, at the same time cannibalistic, of these books, which is striking.
I try to tell, then, the history of the relationship of the Church to healing, and to see little by little, probably around the twelfth or thirteenth century, that a new system of signs appears. not only diseases coming from the gods, but also diseases coming from the body of men. Why? Because the economy is starting to become organized. We are coming out of slavery. The dominant diseases are the epidemics that start to circulate like men and goods. The bodies of poor men carry disease and there is total unity between poverty (which did not exist before because almost everyone was a slave or lord) and disease. poor or sick meant the same thing from the thirteenth to the thirteenth century. So the strategy towards the poor in politics and that towards the sick are no different. is sick, one becomes poor. Sickness and poverty do not yet exist. that exists is to be poor and sick, and, the poor or sick being designated, the good strategy consists in separating it, in containing it, not in curing it but in destroying it: this has been called, in the French texts, to lock it up in Foucault's theses. It is locked up in many ways: quarantine, lazaretto, hospital and in England work-houses. The law on the poor and the charity oe are not means to help people but to designate them as such and to contain them. Charity is nothing other than a form of denunciation.

M. S. - The policeman becomes the therapist instead of the priest.

J. A. -That's it. Religion withdraws and takes power elsewhere because it can no longer assume the power of healing. There are, of course, already doctors, but these only play a role of consolation and, proof of this, the political power, very cleverly, does not yet recognize the doctors' diples. The political power considers that its main therapy is the policeman and not the doctor. Moreover in Europe, at the time, there was only one doctor for 100,000 inhabitants.
But I come to the third period when it is no longer possible to lock up the poor because there are too many of them. On the contrary, they must be maintained because they become workers. They cease to be bodies to become machines. And the signs that we observe are those of the machines. Illness, evil, constitute the breakdown. Clinical language isolates and further objectifies evil. We designate the evil, we separate it and we expel it.
Throughout the nineteenth century, with the new surveillance which is hygiene, the new repair, the new doctor-surgeon separation, we see the policeman and the priest disappear behind the doctor.

M. S. - And today, it's the doctor's turn to fall into the trap ...

J. A. -Today, the crisis is threefold. On the one hand, as in the previous period, the system can no longer operate on its own. Today, in a way, medicine is largely unable to cure all diseases because the costs are getting too high.
On the other hand, there is a loss of credibility of the doctor. Oo has a lot more confidence in the quantified data than in the doctor.
Finally, diseases or forms of behavior appear which are no longer indebted to conventional medicine. These three characteristics lead to a kind of natural continuum which passes from clinical medicine to prosthesis and I have tried to distinguish three phases which are interwoven in this transformation.
In a first phase, the system tries to last by monitoring its financial costs. But this desire leads to the need to monitor behavior and therefore to define standards of health, activities, to which the individual must submit. This is how the concept of a life profile that spares health costs appears.
From then on, we move on to the second phase which is that of self-denunciation of evil thanks to the self-countering tools of behviour . The individual can thus conform to the standard of life profile and become independent from your illness.
The main criterion of behavior was, in i first order, to give a se ns to death, in the second order, to contain the death, in the third order, increase life expectancy, in the fourth, the one we are experiencing, is the search for a profile life saving in health expenses.
The third phase is constituted by the appearance of prostheses which make it possible to designate evil in an industrial way. Thereby, for example, electronic medicines such as the pill coupled with a microcomputer allow to release in the bodies, at regular intervals, of substances, elements of the
regulation.

M. S. - In short, health, with the appearance of these electronic prostheses, will be the new engine of industrial expansion ...

J. A. -Yes, in conclusion, all the traditional concepts disappear: production, consumption disappear, life and death disappear because the prosthesis makes death a moment vague…
I believe that the important thing in life will no longer be to work but to be in a situation to consume, to be a consumer among other consumer machines. The dominant social science until now has been the science of machines. Marx is a clinician because he designates evil, the capitalist class, and he eliminates it. [I hold, in a sense, the same speech as Pasteur. The great dominant social science will be the science of codes, computer science and then genetics. This book is also a book on codes because I am trying to show that there are successive codes: the religious code, the police code, the thermo-dynamic code and today the informational code. called socio-biology.
This theoretical discourse is only useful if the future does not happen: we will only avoid being cannibals by ceasing to be cannibals. I believe that the main thing for a theory to be false is not that it be refutable but refuted. The true is not the refutable, but the refuted.

M. S. - Does your thesis lead to a concrete reflection on medicine, even in the long term? are these the beginnings of a concrete reflection as a politician and economist on the organization of medicine?

J. A. - I don't know. For now, I don't want to ask myself that question. I believe that the first thing that I wanted to show only this is that healing is a process in the midst of ~ transformation towards a model ~ of organization_ which has nothing to do with the present one, and that the choice is between three types of altitude: either to keep medicine today as in the past, or to accept the evolution and ~ area that it is the best possible, with greater equal access to the ~ prosthesis, or a third evolution in which the return to evil is thought of in a new way ,. which is neither that of the p ~ ssé, nor that of the future of the cannibal system; it would be an attitude close to the acceptance of death, so as to make people more aware that the urgent is not to forget, ~ i to reta ~ der! n1 to wait for death, but on the contrary to want life to be as free as possible. So, I think, pe ~ to little! we will focus on these three types of ~ lut! Qns and I want to show, that in my opinion, the last is venerably human.

M. S. - It's social utopia; it is sometimes dangerous to be utopian ...

J. A. - Utopia can have two different characteristics depending on whether we speak of utopia as an absolute dream al ~ rs the dream is a dream of eternity, or whether we refer to the etymology of the word, it is to say to what never took place e ~ on you ~ te alor ~ to see what type of utopia is likely. Now I believe that if we want to understand the health problem, we must realize that there are probable utopias. The future is necessarily a utopia, and it is very important to understand that it is not dangerous since to speak of utopia means to accept the idea that the future has nothing to do with the extensions of current trends.
I would even say all futures are possible except one which would be an extension of the current situation.

M. S. - The future, is it this particular prosthesis that are all these drugs of the future - and of the present - which help man to better endure his condition ...?

J. A. - I find this fascination with drugs against anxiety frightening, anything that can even eliminate anxiety, but as a commodity and not as a way of life.
We try to provide means to make the anxiety tolerable and not. Not to create the functions so as not to be anxious anymore.
Eoswte, all the medicines of the future that are linked to the cost of behavior can have a major political impact.
It would in fact be possible to make parliamentary democracy compatible with totalitarianism since it would suffice to maintain it. all the formal rules of parliamentary democracy may at the same time generalize the use of these products so that the tota litari sme is daily.

M. S. - Does that seem conceivable, a "1984" orwelhen based on a pharmacology of behavior ...

J. A. - I. do not believe in Orwellism, because it is a form of technical! otalttar1s ~ e with a visible and focused "Big Brother". I c ~ o1 ~ i;> read an implicit totalitarianism with a stable and decentralized "Big Brother". These machines for monitoring our health, which we might have for our good, will enslave us for our good. In a way, we will undergo a gentle and permanent conditioning ...

M. S. - How do you see the man of the twentieth century?

J. A. - I believe that we must very clearly distinguish two kinds of men of the twenty-first century, that is to say: the man of the twenty-first century from ~ rich countries ~ and the man of the twenty-first century from the poor countries . The first, at this! Ment a man much more anxious than today but who will find his answer to the evil of living in a passive escape, in the anti-pain and anti-anxiety machines, in drugs, and who will try at all costs to live a kind of commercial form of conviviality.
However, I am convinced that the vast majority who will know about these machines and the way of life of the rich, but who will not have access to them, will be extraordinarily aggressive and violent. It is from this ~ you ~ twist that the great chaos will be born which can be translated either by racial wars of conquest, or by the immigration under our regions of millions of people who will want to share our way of life. .

M. S. - Do you believe that genetic engineering is one of the keys to our future?

J. A. - believe that genetic engineering will be in the next twenty years a technique as banal e, also known and also present in everyday life as the internal combustion engine is today. It is, moreover, the same type of parallel that can be drawn.
With the internal combustion engine, we could make two choices: either to favor public transport and to make people's lives easier, 1, or to produce cars, tools of aggression, of consumption. individualization, loneliness, storage, desire, rivalry ... We chose the second solution. I believe that with genetic engineering we have the same type of choice and I believe that we will also unfortunately choose the second solution. In other words, with genetic engineering we could little by little create the conditions of a humanity assuming itself lightly, but collectively or else create the conditions for a new commodity. genetics this time around, that would be made ~ of. copy ~. men sold to men, chimeras or hybrids used as slaves, robots, means of work ...

M. S. - Is it possible and desirable to live 120 years ...?

J. A. -Medically, I don't know. I have always been told that it is possible. Is this desirable? I will respond sooner or later. First of all, I believe that in the very logic of the industrial system in which we find ourselves, the extension of the lifespan is no longer an objective desired by the logic of power. Why? Because as long as it was a question of extending life expectancy in order to reach the minimum threshold of machine reliability. was perfect.)
But as soon as we move 60/65 bones, the man lives longer that it does not produce and it is dear to society. .
Hence I believe that in the very logic of society industrial, the objective will no longer be to extend the life but to ensure that even within a period of life 'determined the same man as best as possible but in such so that health costs will be as low as possible in terms of costs for the community. Then appears a new criterion of life expectancy: that of the value, of a system ~ e~ aoté, not function of the lengthening: 1st of 1 .esp ~ ran ce of vte but the number of years without illness and hospitalization. Indeed from the point of view of society, it is well preferable that the albumen thing stop abruptly rather
that it does not deteriorate progressively. .
This is perfectly clear if we remember that two thirds of health expenditure is concentrated in the last months of life. Likewise, cynicism aside, health spending does not reach.
would not be a third of the current level (175 billion francs in 1979) if people all died suddenly in car accidents. So we have to recognize that the logic no longer lies in the increase in life expectancy but in that of the length of life without disease. However, I think that the increase in lifespan remains a fantasy which corresponds to two objectives: the first is that of men of power. The increasingly totalitarian and directive societies in which we find ourselves tend to be ruled by "old" men, to become gerontocracies. The second reason lies in the possibility for the capitalist society to make the old ones economically profitable simply by making the old solvent. It is currently a "market", but it is not solvent.
This is entirely in line with the view that man today is no longer important as a worker but as a consumer (because he is replaced by machines in work). So we could accept the idea of ​​extending life expectancy on condition that we make the old people solvent and thus create a market. We can see very well how the current large pharmaceutical companies behave, in relatively egalitarian countries where at least the method of financing retirement is correct: they favor geriatrics, to the detriment of other fields of research such as tropical diseases.
It is therefore a problem of retirement technology that determines the acceptability of the lifespan.
For my part, I know, ~~ -t ~ l..9 \ _le s ~ jalist ~, objectively against extending life because it is a lure, a false problem. I believe that asking yourself this type of problem avoids more essential questions such as that of liberation of the time actually lived in the present life. What good is it to live to 100 years, if we win 20 years of dictatorship.

M. S. - The world to come, "liberal" or "socialist", will need a "biological" morality, to secure an ethics of cloning or euthanasia, for example.

J. A. - Euthanasia will be one of the essential instruments of our future societies in all cases. In a socialist logic, to begin with, the problem arises as follows: socialist logic is freedom and fundamental freedom is suicide; Consequently, the right to direct or indirect suicide is therefore an absolute value in this type of society. In a capitalist society, machioes to kill, prostheses which pn,, nct will eliminate life when it is very unbearable, 4111 economically too expensive, will see the JO ~ r and will be depot current. So I think that euthanasia, what a foolish value of liberty or a commodity, will be one of the rules of future joy.

M. S. - Won't the men of tomorrow be conditioned for psychotropic drugs and subjected to manipulations by the psy.rh1s1ne? How to protect yourself from this?

J. A. - The only precautions that can be taken are knowledge and knowledge. It is essential, today, to prohibit a very large number of drugs, to stop the operation of drugs of the conditioning; but maybe the border has already been crossed ... 1 ist that, of its cé, television is not a drug i, xccssive?
Hasn't alcohol always been a drug?
The worst drug is the absence of culture. IndiV1du ~ see drugs because they have no culture. Why do they seek drug alienation? Because they have taken cognizance of their powerlessness to live and that this powerlessness 'I \' translates concretely into the total refusal of life.
An optimistic bet on man would be to say that ~ i man ~ invents culture, in the sense of the tools of thought, he could raise him to solutions of impotence. Don ~, take the badly, it is to give men a formidable instrument of "ubversion and creativity.
I don't think banning drugs would be enough 1'111 if we do not attack a problem at. its root, <;> n falls
They get stuck with the police and it is worse.

M. S. - How are we going to deal with mental illness in the future?

J. A. - The problem of the evolution of the medicine: cine des This mental illness will take place in two stages. In a first time ~ There will be more drugs, the p ~ ychotropes, which corresponsive to real progress, over the past 30 years, in the 111 mental medicine.
It seems to me that, in a second step, and for reasons ti: o nomiques, a number of means will be put in place Electronic, which will be either methods of controlling the (bio-feed-back, etc.), or an ioformattque system of Psychoanalytic dialogues.
., This é ~ oluti_o? a ~ ra for consequence to lead to what J call ~ 1 exphc 1tat1on of normal; that is to say that the electronic means make it possible to define with precision the normal and to quantify the social behavior. The latter will become economically consumable since there will be the means and the criteria of co ~ for mity a_ux standards. In the long term, when the disease is conquered, there is the temptation to conform to the "biological normal" which conditions the functioning of an absolute social organization.
Medicine is indicative of the evolution of a society which is moving towards decentralized totalitarianism. We already perceive a certain conscious or unconscious desire to conform as much as possible to social norms.

M. S. - Do you see this forced normalization governing all areas of life, including sexuality, since science allows and today the almost total dissociation of sexuality and conception? ...

J. A. - From an economic point of view, there are two reasons which allow me to think that we will go very far.
The first concerns the fact that men's production is not yet a market like any other. By following the logic of my general reasoning, we do not see why procreation will not become an economic product like others.
One can perfectly imagine that the family or the woman are only one of the means of production of a particular object, the child.
We can, in a way, imagine “allocation matrices” which are already technically possible. This idea fully corresponds to an economic development in the sense that the woman or the couple will be part of the division of labor and general production. Thus it will be possible to buy children as one buys "peanuts" or a television set.
A second important reason and linked to the first could explain this new family order. If on the economic level the child is a commodity like any other, society I also consider it that way, but for social reasons. Indeed, the survival of the communities depends on sufficient demography for their survival. S1 for economic reasons the family does not wish to have more than two children, this attitude is obviously opposed to the interest of the community! There is thus an absolute contradiction between the interests of the family and that of ln ~ 11l: 1é1é. The only way to resolve this contradiction is if society can buy children from a family which is paid in return. I'm not thinking of 111111llinlcs allocations which are weak incentives. A family would accept, to see you many children if the State guaranteed them on the one hand 1 payment of substantial progressive allowances and on the other 111111 full support for the material life of each 11111. l) in this schema, the child will become a kind of currency! the hunge in the relations between the individual and the collectivity.
(· What I say there is not on my part a kind of complacency, it comes from 111 cc which seems inevitable. It is a warning. I believe that any one in preparation will be so dreadful that it means It is necessary to prepare to resist it and I N111111) today that the best way to do it is to start, to accept the fight, to avoid the worst. . It is for 11,111 that I push my reasoning to the limit. ..

M. S. - Rési ste r what, since you are announcing an 11111 inevitable vcrs of prostheses?

J. A. - The prostheses that I see coming are not mechanical. Q11c ~ n1ais its means of fighting against affections, h11111iqucs linked to the phenomenon of tissue degeneration. The lt.-u, cllular, genetic engineering and cloning prepare the lt tci pathway. prostheses which will be regenerated organs replacing the "'~ some failing.

M. S. - The growing penetration of IT in the H1 .1 • ié1é invites ethical reflection. Isn't there an underlying 1111 · n1H: C for human freedom?

J. A. - It is clear that the discourse on prevention, the importance of health, good medical practice, leads to 111 ntccssity for each individual to have a medical file which will be put on a magnetic tape. ~ e. For reasons ~ p, d <: n1iological, all of these backs ~ 1ers will be centralized 411111s a computer to which doctors will have access. The question arises: will the police be able to access these 1 "h11.:rs? I can honestly note that Sweden currently has this kind of sophisticated system and does not know
111111 aulant of dictatorship. I will add that some countries do not have 1, • 1 • s files but on the other hand a dicta tur e. Sachon s threats create a bulwark for new procedures. The il1'111ocracy has the duty to adapt to technical developments. Constitutions associated with new technologies can lead to totalitarian systems.

M. S. - One of the most common projections on the future foresees that man will be able to exert a biological counter on his own body, among other things, thanks to microprocessors ...

J. A. - This cons already exists for the heart through "pacemakers", and also for the pancreas. It should extend to other areas such as pain. There are plans to develop small implants in the body capable of releasing hormones and active substances into target organs. If it aims to prolong life, this progress is inevitable.

M. S. - It seems that