John A. Vincent “Ageing Contested”

Vincent, John A. 2006. Ageing Contested: Anti-ageing Science and the Cultural Construction of Old Age. Sociology 40(4): 681-698.

He starts from an evolutionary perspective, pointing out that different animal lifespans are an adaptive response to the hazards in their environment. Entropy leads everyone to age; thus ‘the eventual failure of maintenance leads to senescence, death in old age and the return to disorder’ (Holliday, 2000: 97). Ageing is failure to repair defects in ‘DNA or protein molecules’. So ageing is to do with what goes wrong in old age, with failure. (683)

„Senectitude in 1481 originally meant old age; senescencewas used in 1695 to mean growing old; and senile was used in 1661 to signify what was suited to old age. The term senility was used in 1791 to mean a state of being old or infirm due to old age. But by 1848 senilemeant weakness, and by the late nineteenth century it indicateda pathological state (Covey 1988, 294; Haber 1983, 73–74; Kirk 1992, 491). The term has taken on greater medical negative connotations ever since.” (Katz, 1996: 41) (686)

Four types of anti-ageing science:
1) Symptom alleviation: Thus one type of anti-ageing medicine that the scientific biogerontologists separate themselves from might be called symptom alleviation. These are attempts to hide, postpone or relieve the effects of biological ageing. While such techniques have been practised for most of history, new methods can be devised using the knowledge, experimental method and technical sophistication of modern science. These new techniques are subject to an enormous commercialization potential (Estes, 1979; Estes et al., 1984). Three subcategories of this type of anti-ageing medicine can be identified: (1) cosmetic – powder and paint, anti-wrinkle cream, etc., to disguise the signs of ageing; (2) prophylactic – exercise and diet or vitamin pills to stave off the onset of physical ageing and its signs; and (3) compensatory – Viagra and HRT, designed to re-invigorate ‘failing’ functions to a youthful standard. […] Thus the implicit definition of old age in this form of anti-ageing medicine is that of appearance. To look old is to be old. The boundary between youth and old age in this way of looking at the world is marked by physical appearance. (689)
2) Life expectancy extension: Thus the dominant view of old age that comes from this discourse sees it as a stage in life medically defined wherein people are in the first instance ‘at risk’ from a set of specific diseases and thereafter afflicted by them. Old age from this perspective is not fundamentally about appearance of the body per se, but about the diseased condition of the human body. What distinguishes old age from youth is its disease status. Thus people no longer die of old age but of a specific disease. These days most gerontologists, whether biologists, medics or social scientists, tend to define their objectives in terms of ‘health span’, that is to say the extension of illness-free years of life. Such consensus nevertheless leaves a serious unresolved ambiguity about extending life for its own sake. This dilemma is hidden if old age is simply thought of as a disease; ill health is by definition bad, but wanting to be healthy is not the same as wanting to live forever. (690)
3) Lifespan extension: Combating disease may increase life expectancy, but some bio-gerontologists make claims to increase the lifespan. These disputes as to whether there is a natural lifespan that is independent of death from specific diseases are about establishing scientific credibility for anti-ageing science in the specific form of research into genetics and cellular senescence. Key issues in the control of ageing are identifying genes for ageing, limiting metabolic and oxidation damage, removal of worn-out or damaged cells, cell replication and protection, use of stem cells for replacement therapies and combating the reduced efficiency of the immune system with age. (690-691)
This view detaches old age from the level of the organism and the level of humanity. It is worth noting Rose’s (1997) criticism that modern biology does not pay sufficient attention to the whole organism, in this case the whole human being (cf. Dupré, 2002). He powerfully argues that biology neglects the totalizing, broader picture of the whole organism, concentrating instead on cells, genes and biochemical processes. In the literature considered above, there is a fuzziness about the human identity of the phenomena which age. There is a whole unspoken level at which people’s identity and their values and motivations are simply taken for granted. (691)
4) Abolition: Some bio-gerontologists do indeed make the explicit claim that it will be possible to reverse ageing or to create immortality (cf. Shostak, 2002). However, many participants in such research deny this and profess not to see the connection (de Grey, 2003; Turner, 2004). The boundary problem for them is to position modern bio-gerontology outside the realm of fantastical claims discredited in the past, and limited to a technical debate rather than an ethical or ‘sociological’ agenda. Immortality is not a new objective. It has been the implicit goal of post-Enlightenment science and its aim of perfecting humans through progress. It is subject to not only biological speculation but also philosophical and cultural debate. Most thought experiments with immortality portray it as a dystopia (e.g. Raikhel, 2000).(692)

The most efficient way with currently available technology to extend human lifeexpectancy would be to devote resources to reducing infant mortality in the developing world. This, of course, would do nothing for the human lifespan. Within the framework of a culture that equates science with progress and human domination of nature with success, old age will forever be condemned as the failure of scientific modernity. (693)

Wherever bio-gerontologists are positioned in the fourfold classification outlined above, they all start with the view that human ageing is primarily a biological process capable of technical control. The modern dilemma involved in constructing nature as separate from humanity and subject to its control leads to cultural ambivalence towards scientifically engineered life extension (Bauman, 1991). (693)

There is an irredeemable cultural logic – if death is a solvable problem, then old age will be a failure. Only by re-naturalizing the idea of a ‘healthy death’ can we reconstruct a positive old age. It is a tribute to the power of the biomedical model of old age that many find it difficult to think of such a phrase as meaningful, or misconstrue it as a euphemism for euthanasia. However, for old age to be seen as a successful conclusion to life requires life to be defined culturally in other ways than as the continuation of bodily functions (Vincent, 2003a). (694)

Céline Lafontaine “Regenerative Medicine’s Immortal Body”

Lafontaine, Céline 2009. Regenerative Medicine’s Immortal Body: From the Fight against Ageing to the Extension of Longevity. Body & Society, 15(4): 53-71.

As a re-engineering of the body, regenerative medicine is the most accomplished manifestation of biopolitics: it concretely announces the emergence of a ‘culture of life’ in which individual existence is symbolically assimilated to biological conditions (Knorr Cetina, 2005). (54)

In this way, regenerative disease constitutes one of the primary avenues of a postmortal society in which death is considered a disease or an accident that can be avoided thanks to control and safety devices (Lafontaine, 2008). (54)

While as recently as the beginning of the 20th century, death haunted the cradle, attacking infants and birthing mothers, it has since taken on the traits of a fragile and sickly old man, patiently waiting for Death to come and take him away. All caricatures aside, it is true that, until recently, the increased life expectancy in developed societies was essentially due to lowered infant and mother mortality rates (Yonnet, 2006). (55)

In a shocking French publication entitled La Guerre des âges[The War of the Ages], researcher Jérôme Pellissier (2007) shows how older people have become the scapegoats of our time. Seen as a threat to progress and prosperity, old age is likened, in some people’s eyes, to a reef on which society may run aground and sink. Extending greatly beyond the scope of France, this negative representation of old age is found in most Western societies. Whether it is a question of economic productivity, the cost of health care or political conservatism, the ageing of the population is named in many socio-economic studies as a factor contributing to stagnation and regression (Pellissier, 2007). (56)

The social construction of old age as a problem is, in fact, directly connected to the biologization of old age, and its representation in terms of decadence and decrepitude. Therefore, it is not so much age but rather the physical signs of ageing that are the source of stigmatization (Gilleard, 2005: 162). (56-57)

The discrimination against the elderly seems, to a great extent, to be connected with their increased social visibility. Vulnerable and fragile, they are now considered to be victims condemned to degeneration, accepting the verdict of announced death without budging (Mykytyn, 2006a: 646–7). This victimization of older people presumes that ageing is a form of terminal illness that must be treated since it cannot be eliminated. (57)

Inseparable from the sexual revolution of the 1960s and 1970s, the affirmation of autonomy and youth stems from a representation of personal freedom as pleasure and enjoyment. First focused on the physiological maladies connected with menopause, research on ageing came to see reduced sexual functioning as a medical disorder that could be treated and controlled (Staehelin, 2005: 173). In following this trend, hormonal therapy – in this case estrogen shots intended to preserve menopausal women’s vitality and femininity – quickly became commonplace in developed societies (Marshall and Katz, 2002: 44–5). However, it was only with the availability of Viagra in 1998 that the medicalization of ageing took on its full meaning. So much so that this pill for erectile dysfunction has become a symbol of modernity. (59)

Perfectly falling in step with the concept of biopower as described by Foucault (1976), age-related erectile problems became a public health problem over the course of the 1990s, on equal standing with obesity and diabetes. Causing loss of autonomy and enjoyment, erectile difficulties are not only the object of biomedical research, they are also associated with degeneration. Therefore, everything occurs as if ‘the erect penis is now elevated to the status of a vital organ’ (Marshall and Katz, 2002: 59). The message, which conveys the social discourse around Viagra, comes to no more and no less than erectile loss as a precursor to death (2002: 58–9). (59)

Merging normal and pathological, regenerative medicine aims to reproduce the biological processes that allow the body to repair itself, and even recreate itself. Therefore, it is no longer a question of conserving the body in a state of balance to fight against disease, as it is for modern medicine, but rather to fight degeneration itself. Thus, the objective is no longer healing, it is regeneration, which in itself presumes no limit. (62)

For the researcher Stanley Shostak, it is clear that the future of biology resides in the recycling of bodily waste: ‘Some biologists have come to appreciate that life itself depends on the recycling of wastes and corpses’ (2002: 35). Despite their controversial social and legal status, embryonic stem cells are part of this notion of biological recycling. The use of ‘surplus’ embryos for experiments is justified because these precious vital resources should not be ‘wasted’ (Waldby, 2002: 317). Created for in vitro fertilization, these embryos are not the object of ‘a parental project’ and are therefore recycled into biomedical products available for research via a biomedical standardization process (Tournay, 2007). (63)

The experimental treatments Geron offers greatly exceed the scope of healthcare systems and, therefore, access to this private treatment depends entirely on patients’ capacity to pay for it (Mykytyn, 2006a: 649). Indeed, as anthropologist Sarah Franklin explains, Geron capitalizes on the search for immortality by a clever marketing of scientific advances that stem as much from speculation as from real accomplishments (2003: 123). In this way, what is sold is simply the dream of controlling and reprogramming the human mechanism to make it potentially immortal. (63)

‘It is rational to want a longer life because life itself is the precondition for all else that we might want. At its most fundamental level, prolonged life offers the opportunity for additional and varied experiences’ (Overall, 2003: 184). Stemming from the concept of freedom in terms of individual enjoyment and increased personal experiences, contemporary narcissism would appear to be inseparable from the biologization of culture, in that pursuing life in and of itself becomes an objective independent of all other cultural, social or political dimensions (Knorr Cetina, 2005). (67)

Nikolas Rose “The Human Sciences in a Biological Age”

Rose, Nikolas 2013. The Human Sciences in a Biological Age. Theory, Culture & Society, 30(1): 3-34.

First, the contemporary life sciences – in genomics, in the understanding of the cell and the processes of development and differentiation, in molecular neuroscience – reveal multiple affinities between humans and other creatures, and throw new light on their differences. (5)

Yet alongside this reduction of life to the interaction of its smallest components, another style of thought has taken shape. This way of thinking construes vital properties as emergent, and living organisms as dynamic and complex systems, located in a dimension of temporality and

development, and constitutively open to their milieu – a milieu that ranges in scale from the intracellular to psychological, biographical, social and cultural. One of the key conceptual struggles in the sciences of the living – which one can find in almost every area – concerns the relations between these two visions. (5)

Hence, second, we have seen the ‘technologization’ of vitality in the life sciences. It is not only that to know is to intervene, although that is crucial: one knows life today only by intervening in it. (5-6)

Intervention is not just to know, but also to do: knowing life at the molecular level has been intrinsically related to an enhanced capacity to act upon it at that level. Life itself – that is to say, the living of the living organism – seems to have become amenable to intervention and open to projects of control. (6)

Paths to the creation of biological truths have been shaped by promises and predictions of the

biovalue to be harvested – enhanced crop yields, bioenergy, bioremediation, and, of course, advanced medical and health technologies based on biology. (6)

[…] a third feature of contemporary biology that calls for attention by the social and human sciences: the salience that the biological and the biomedical has achieved in practices of self-management and self-governance. (6)

To live well today is to live in the light of biomedicine. (7)

This is asserted via a mind-bending amalgam of the usual suspects from philosophy – Agamben, Bergson, Deleuze and Guattari, William James, Spinoza and Whitehead – together with references to Simondon and von Uexku¨ll and a few biologists or neuroscientists: LeDoux, Damasio, Ekman, the famous autist Temple Grandin, Libet, and of course the Buddhist neuroscientist Francisco Varela. These figures are called upon to support the argument that it is only by recognizing the true nature of human corporeality and the power of the affective that we will be able to free ourselves from an overly intellectualist and rationalist account of contemporary politics, economics and culture. Only then will we be able to grasp, and perhaps to intensify, the non-conscious, non-intellectual level forces that inspire resistance, creativity and hope. Biology is translated into ontology, ontology is transmuted into politics. We have seen a similar move in recent history, appealing to a different biology, with political consequences that, to say the least, should give us pause. (12)

A strange form of conceptual gerrymandering seems to underpin such ‘liberation biology’: biological claims evade critical interrogation where they seem to give support to a pre-given philosophical ethopolitics. This is a mirror image of the notorious tendency of life scientists to support socio-political arguments by transposing their research on flies or mice directly to the realm of human society and culture. (12)

And those from the social and human sciences rightly identify the impoverished sense in which, in these imaging experiments, ‘social relations’ are reduced to interactions between dyads that can be experimentally simulated in a laboratory and in a scanner (Cohn, 2004, 2008a, 2008b). (16)

Genomics has moved away from a style of thought that looked for single genes for specific characteristics, the ‘gene-for’ paradigm so criticized by social scientists, especially when it claimed to have discovered ‘the gene for’ an aspect of the human condition, such as homosexuality or bipolar disorder. While the Human Genome Project was initially underpinned by the idea that the sequence of the genome would be ‘the code of codes’ or ‘the book of life’ – the digital instructions for making a human being – the real itself intervened to say no. The evidence from sequencing of humans and other organisms simply did not support the view that genes were distinct units, each of which coded for a single protein. Instead, it became clear that each sequence of bases could be ‘read’ in many different ways, thus enabling a small number of coding regions to generate a large number of different proteins. (17)

This led to the first significant mutation in thought styles: a shift away from determinism towards a probabilistic way of thinking about the relationship between genetics, development, evolution, organism and life chances. (17)

We are moving away from the idea that each common disease will share the same genomic basis – even if a complex one – to a model where common diseases are the endpoints of many different, rare genomic variations. Even in conditions where we have a clear idea of heritability, such as certain forms of breast cancer, the proportion explained by what we know of genomics is small and the ‘missing heritability’ – which cannot be explained by genetics – is high, ranging from 50 percent for age-related macular degeneration, 20 percent in Crohn’s disease and around 95 percent in elevated lipid levels (Manolio et al., 2009). (18)

This is a form of argument that links to, but goes beyond, the important recognition that human capacities such as cognition and affect are ‘distributed’ – not the individuated property of singular organisms, but constitutively dependent on the webs of interactions among multiple organic processes within and between organisms and other entities in a locale. Of course this thought style operates in very different ways in different disciplinary domains, and there is no single way that the social and human sciences might make their links with them. But it is clear that such links will not be in terms of the relations of ‘body’ and ‘society’ – those enticing yet illusory totalities – but at a different scale. Not in terms of ‘the body’ or ‘the brain’ as coherent systems enclosed by a boundary of skin, but of bodies and brains as ,ultiplicities, of the coexistence and symbiosis of multiple entities from bacterial flora in the gut, to the proliferation of neurons in the brain, each in multiple connections with milieux, internal and external, inorganic, organic, vital, historical, cultural, human. Distributed capacities in milieux which vital organisms themselves partly create and which in turn create them and their capacities. (19-20)

Joanna Latimer “Rewriting Bodies, Portraiting Persons?”

Latimer, Joanna 2013. Rewriting Bodies, Portraiting Persons? The New Genetics, the Clinic and the Figure of the Human. Body & Society 19(4): 3-31.

By suggesting how bodies are not, as previously understood, bounded, contained, homogeneous, fixed and integrated entities, the individual whole persons of humanist thought, made up of substance that is uniquely them, emergent understandings from the biosciences have the possibility of changing perceptions of the body, and thereby of the existence of human beings. That is, contemporary discoveries in molecular biology seem to trouble the self/not-self division that is the defining feature performed by the figure of the individual body. (7)

The new genetics thus puts into play an idea that ‘[w]ithin ‘‘us’’ is the most threatening other – the propagules, whose phenotype we temporarily are’ (Haraway, 1991: 217). Second, breakthroughs made possible because of new genetic techno-science offer ways of rethinking body-persons as made up of substance from a much wider gene pool, and of the body as the temporary and partial expression of a genotype. Within this perspective it is the DNA that is immortal, and the genes that are the ‘time travellers’, while the body or soma is just the transport vehicle, the hired car, the temporary and dispensable host for their reproduction (Olshansky and Carnes, 2001). (7)

Medical textbooks are full of such images. These portraits are classic depictions of a human figure in a specific pose, such as Londe’s portrait of hysteria (Figure 1). The figure is taken not so much to represent him- or herself, but as representing the disease category to which they are being assigned: the figure is being read as signifying the pathology. But engaging with clinical pictures as forms of portraiture is also important because, as Jordanova suggests (2000, 2003), portraits are mobile objects that circulate culturally and socially specific ideas about body–self relations and personhood. For example, Albert Londe’s portrait shows that the effects of hysteria are totalizing, so that the woman embodies the illness. But the form of the portrait also individuates, not just hysteria, but the body-self and personhood. (11)

Clinicians draw upon these clinical methods of assemblage and juxtaposition to differentiate when what is abnormal or unusual about bodies, parts, persons and even families, represents a phenotype. This is because for the most part, there is no genetic technology (molecular test) that can make anomalies visible at the molecular level (see also Reardon and Donnai, 2007). (13)

The relation that gets implied in how dysmorphologists construct their clinical pictures is between the particular features of a syndrome, the notion of a phenotype, and, as such, perhaps the expression of an atypical, aberrant genotype. At moments, it is this relation, the syndrome–genotype, that dysmorphology’s portraits evoke. The aberrations may be as tiny as a single gene defect. For example, where, to use the expression of one expert, ‘a bit of chromosome has fallen off and landed in the wrong place’. The suggestion implied by how geneticists assemble their clinical pictures, then, is that how people and their bodies look and function (the phenotype) may not just be evidence of a syndrome but also that the syndrome is the effect of a specific aberrant (but as yet invisible) genotype, a syndrome–genotype relation. (14)

The portrait in dysmorphology does not always reduce to the figure of an individual, rather the figure of a syndrome–genotype relation emerges in the partial connection between the assemblage and juxtaposition of materials deriving from different bodies. In the clinic the portrait makes a (temporary) space that cannot (yet) settle all the division and connections between all the parts across different bodies. And it is this that is the defining feature of some of dysmorphology’s portraits. The complexity and heterogeneity of the defining features of a syndrome need to be distributedfor them to stand as a phenotype, and the visible expression of the syndrome–genotype relation. Critically, what is implicit in these juxtapositions and dysmorphologists’ readings of them, is that there is something about the substance of the bodies of individuals that is not unique to them, but is shared, or at least held in common, to use Strathern’s term. What is exceptional is being able to make the portraits show that it is not simply a disease that is shared, rather it is the common genetic substance, the genotype, that is pathological, and that the syndrome is the expression, or phenotype, of this common genotype, distributed across different bodies. (18)

Rather, what dysmorphology’s portraits perform is that it is the syndrome–genotype that is made of fragments, not persons. (19)

At the same time, then, as the face of a child may be effaced (Bauman, 1990) by the genetic, the actors responsible for them – the clinicians, the parents – are not effacing their humanity even as they constitute their abnormality. It is the syndrome–genotype that does that. This means that at the same time as clinicians draw upon a notion that the child’s condition is biologically determined rather than socially or culturally conditioned, they hold to an idea that there is an essence to persons, that people have a real nature, that a child is unique and essentially human, despite abnormalities of appearances, appearances on the surface and in the depths of the body. In these ways the integral, discrete body is what helps to create the figure of the individual, but the individual, to be truly human, and transcend their bodiedness, must be able to ‘disembody’. (21)

The relation between the integral, contained, corporeal body and that of the autonomous individual helps perform the figure of the human. This figure of the human isthe cultural icon that underpins most contemporary forms of social organization in the West, including sociological theory itself (Skeggs, 2004, 2011; Strathern, 2006). But alongside this idea of the individuated body-self, runs the paradoxical and parallel seam of western thought that detaches rationality from the body: the individual, at moments of choice and autonomous decision-making, to be rational, must have knowledge from a singular, undivided perspective, a perspective that stands outside the plane of personal (that is bodily) action (Latimer, 2007a; Strathern, 1992). (22)

Against notions of the integral, contained body, individuals, to be fully human, also have to demonstrate a capacity for detachment. To attain the singular perspective of rationality, ‘man’ must be able to disembody. (22)

Paradoxically it is the figure of the person as integral body and a unique discrete consciousness that helps to portray the individual as human. To be fully human, and transcend their bodiedness, the individual must be able to detach rather than simply ‘disembody’, as many have read Descartes (Foucault, 1979). (22)

The human, once distinguished by this detachment of consciousness, is thus able to settle into a complex whole. Curiously it is not the envelope of the body, its form that can be caught in paint or a photograph, so much as it is this signing of a detachment of consciousness from bodily experiences that defines the individual. Yes, representations of the corporeal body must take up most of the painting, photograph or sculpture, but it is the capture of the character (the eyes, stance and gesture) that enliven the flesh and make these more than a representation of a corpse. To be seen as human, persons must exhibit characteristics, such as willpower, desire, vulnerability or moral strength. (23)

The figure of the individual is thus performed as a distinctive person who is much more than the sum of their bodily parts. This doubling of figures is one of the paradoxes of dominant body–self relations. (23)

Rebecca J. Lester “Brokering Authenticity”

Lester, Rebecca J. 2009. Brokering Authenticity: Borderline Personality Disorder and the Ethics of Care in an American Eating Disorder Clinic. Current Antrhopology 50(3): 281-302.

Managed care is first and foremost an economic model; a system of organizing and rationing health care services within a capitalist system where market forces determine both the cost and value of those services. Built on a rational-choice model of human action with profitability as the ultimate good, managed care is predicated on the stan-dardization of a product (health care) across domains, a reg-ulation of the provision of that product, and a rationing of the supply of the product in order to maximize economic profit and minimize loss (Baily 2003; Goldman 1995; Peterson 1998). To do this, managed care organizations (MCOs), such as Blue Cross, Aetna, United Healthcare, and so forth, con-tract with hospitals and providers to offer services to sub-scribers at reduced costs—what Donald (2001) calls “the Wal-Marting of American psychiatry.” (282)

How, then, do clinicians navigate this minefield of managed care and still feel ethical about what they do? (282)

It is clear, then, that the vast majority of clinicians view managed care as the enemy and perhaps almost as harmful to the client’s health as the eating disorder itself (see also Robins 2001; Ware et al. 2000). How then do eating disorder clinicians function within such a system? (284)

Borderline talk at Cedar Grove is a mode of everyday dis-course among clinicians that invokes BPD to shorthand clus-ters of behavioral and interpersonal concerns. It takes a number of forms. It can be explanatory, accounting for a client’s behavior (“She’s really borderline. She can’t handle that kind of feedback from her peers without going into crisis”). It can be cautionary, as a way of preparing another clinician for an encounter (“Watch out! She’s in full borderline mode to-day!”). It can also become a way for therapists to communicate to each other their personal struggles or even burn out (like the Dementors comment). (285)

The standard managed care view is very different from Cedar Grove’s. In synergy with biomedical psychiatry and cognitive-behavioral approaches (which enable controlled outcomes research and, therefore, lend themselves to cost-benefit analyses in ways psychodynamic approaches do not), managed care tends to figure these illnesses as episodic

cognitive-behavioral dysfunctions that are essentially resolved once the symptoms abate (Wiseman et al 2001). From this perspective, unlearning an eating disorder rests primarily on interventions targeting the specific behaviors involved (food rituals, caloric restriction, purging). The underlying causes and ongoing functions of an eating disorder are not a focus of concern, and issues such as “voice” or “sense of self” are deemed irrelevant. Managed care rests on a rational choice model that presumes people act out of a desire for self-preservation. (286)

“Psychodynamic” is a somewhat generic term that can include a number of different schools of thought, but we can rea-sonably characterize as “psychodynamic” those approaches that entail the following core set of assumptions about human behavior, human motivation, and psychiatric distress: (1) Hu-man behavior is meaningful. This is thought to be true even when the meaning of the behavior is not readily apparent to the individual, the clinician, or others; (2) The meanings of human behavior derive from an interaction between an in-dividual’s life experiences and current social context; (3) The meanings of behavior are closely entangled with an individ-ual’s cognitive and emotional processes, which tend to or-ganize themselves in functional response to an individual’s social and interpersonal environments over time; (4) Indi-viduals themselves may not be aware of the meanings of their behaviors or the substrates of emotion and cognition that motivate them and can even be perplexed or distressed by them; and (5) Therapists and other mental health profes-sionals are specially trained to help individuals uncover the meanings of their behaviors (why they do what they do) or the origins of distress (why they think what they think, or why they feel what they feel). (288)

[…] the idea that mental health is characterized by the development and solidification of the “self” as a seat of largely independent thought, motivation, and action is central to all such models. Specifically, the notion that a healthy self is a “true” self forms the core of the psychodynamic approach. Authenticity, in its epistemic sense, then, is viewed as necessary for the achievement of healthy autonomy. (288-289)

The managed care approach to health care rests on propositions that sit uneasily with those central to the psychody-namic approach. Specifically, the managed care model is built on a notion of autonomy as entailing procedural, versus ep-istemic, authenticity. In this view, authenticity involves the development of capacities to act in accordance with the values and ideals one endorses. Here, authenticity refers more to a consistency of action within a moral system rather than an expression of intrinsic, essential self. Authenticity in this sense involves bringing a subject’s actions in line with the ideolog-ical commitments she espouses. To act authentically means to behave in a way that is consistent with these values. (289)

Contrary to managed care’s rational choice assumption that an individual’s prime directive is self-preservation, the psychodynamic perspective recognizes that mental illness often entails self-destructive intention (e.g., su-icidal gestures, poor self-care, social isolation), the causes of which are frequently outside an individual’s conscious awareness. (289)

Unlike the psychodynamic view, the managed care perspective understands psychiatric distress as episodic rather than endemic, as a “state” the per-son is in versus a “trait” that endures. Using a somewhat different theoretical lexicon, we might say that the managed care model construes authenticity as a technology of action, whereas the psychodynamic model con-strues authenticity as a technology of self (Foucault et al 1988). (290)

Specifically, borderline talk engages the conflicts between procedural and epistemic authenticity in a singular, if dis-turbing, way—by rendering epistemic authenticity itself impossible. (292)

If, to paraphrase Rhodes’s prison guard, Caroline’s behavior is construed as manipulative in large part precisely because she is a manipulator, then it becomes difficult for the clinical team to ever perceive her as acting authentically, regardless of her motivations. In a context where authenticity (procedural, epistemic, or both) is un-derstood as foundational to autonomy and psychological health, this rendering of Caroline as incapable of epistemic authenticity—because she has no authentic self from which to act—configures her as largely outside the purview of rea-sonable clinical intervention. It therefore upholds an evaluation of her treatment based on her outward actions alone. Under such circumstances, it becomes not only acceptable but ethical to discharge her from treatment until and unless she is prepared to invest in her own care, with the burden for demonstrating this readiness resting squarely with her. (293)

We can see how, in cases like Caroline’s, invoking borderline talk enables a provisional resolution of the authenticity problem by rendering any reliable subjectivity at all unattainable for a given client. This, of course, requires clinicians to negate the very thing they claim necessitates their existence as trained professionals—the “self” as an entity deserving of care. At the same time, this practice affirms and supports the ends of the managed care organizations. (293)

Robert Castel, Francoise Castel, Anne Lovell “The Psychiatric Society”

Castel, Robert; Francoise Castel; Anne Lovell 1982. The Psychiatric Society. New York: Columbia University Press.

 

Part Three: Psychamerica

With the advent of mental medicine, the lunatic came to be seen as a patient suffereing from a malady. For the first time, a distinction was made between the mentally ill individual and others belonging to such miscellanous categories as social deviants, delinquents, vagabonds, vagrants, debauchees, wastrels, idiots, criminals, and others guilty of violating social and sexual norms. (171)

The nosographic classifications of mental illness have always been dubious, however. They are based on the assumption that there is a clear divdiding line between people who are „ill“ and therefore within the purview of psychiatry, on the one hand, and people who are „normal“ – though they may come under the jurisdiction of some other repressive agency, such as the courts – on the other hand. (171)

The people who seek these new services exhibit symptoms that are signs not so much of a specific pathology as of a malaise in daily life: exaggerating somewhat, one might say that what must be cured is normality. Now that we have reached the point of „therapy for the normal“, virtually all of social space has been opened up to the new techniques of psychological manipulation. (172)

 

Chapter 6: The Psychiatrization of Difference

In many police departments social workers are on call around the clock. There are „roving medical teams“ which include a psychologist and an intern who work for the police. This gives mental health personnel access through the police to people who would never have thought of seeking psychiatric help on their own, particularly in the ghettos and other poor areas. (177)

American courts confront a basic contradiction. Unable to mete out the prison sentences provided for by law, they discharge their responsibilities by sending lawbreakers to community treatment programs, most of which the judges know to be shams. What makes this deceit credible is that the concept of „treatment“ is invoked – in other words, the contention is that techniques based on medicine will be used to rehabilitate delinquents. Were it not for this safety valve, perhaps the fiction that justice is being done by the courts would have been exploded long ago, and people might then have been willing to look more closely at the foundations of a legal system (and a society) so conceived that nearly a third of the nation’s young people violate its laws. Rather than raise basic questions about the system, people have cast about for dubious alternative to what are ostensibly the most brutal forms of punishment. What is paradoxical about all but a few of these „alternatives“ is that they have done nothing to empty the prisons while augmenting the number of people mixed up with the courts. (183)

[…] the legal criterion for accepting or rejecting experimentation of this sort turned on the degree to which the technique in question was genuinely „medical“. (188)

According to some estimates, however, the number of addicts was most likely higher in the early twenties than it is today, perhaps nearly as high as one million. But addiction was not yet recognized as a social scourge. What has happened lately is not so much a drug „epidemic“ – a term suggestuve of the medicalization of the problem – as a stepping up of coordinated efforts to control certain social groups. (190)

In retrospect, the nineteenth and realy twentiet centuiries have been called a „drug addicts’ paradise“: morphine and heroin were widely used both for medical purposes (in the treatment of alcoholicm, as sedatives, and for „women’s troubles“) and simply for pleasure. The definition of a substance as a drug is a social act and goes hand in hand with efforts to restrict its use. (191)

[…] methadone has two decisive advantages in connection with drug control policy: there is no withdrawal, so users are less likely to be drive to violent crime in search of drugs or money to satisfy their craving, and users become dependent on methadone and are thereby forced to submit to daily scrutiny by the medical personnel who dispence the drug. Official documents recognize the fact that methadone users are in a dependent state and hold that this is one key to its effectiveness. One stated that many addicts have difficulty forming close relationships, and if they were not dependent on metadone, they would find it difficult if not impossible to go to the dispensary every day and establish a long-term relationship with the staff. Thus the dependence created by methadone is crucial to establishing a potentially therapeutic and rehabilitatice relationship with the addict. (197)

The new techniques have made it possible to tighten surveillance and control and extend their range. If prisons are beginning to look like hospitals, this means that their claim to provide therapy is not incompatible with their repressive function. (202)

For children even more than adults, psychiatric labels are often thin disguises for difficulties in adjusting to specific social, family, or scholastic situations rather than descriptions of clear-cut pathologies. (202)

The present goal is not merely to segregate abnormal individuals but also to detect potentially troublesome cases early on. One element of the new stategy is to examine everyone belonging to certain specific social groups or age categories. (204)

Schools are increasingly being used to separate the wheat from the chaff, the normal from the pathological, and growing numbers of specialists are being trained to assist, cousel, and treat what might be calles „abnormal pupils.“ (206)

Thus it seems clear that the real target of the treatment is the child’s disruptive behavior per se. The therapeutic excuse for the use of these drugs has been abandoned, and they are now openly accepted as instruments of control. As one pediatrician has put it, the object of medication is to improve the functioning of the brain so that the child becomes more normal in his thinking and responses. (209)

[…] childhood in general has become the prime target of an indiscriminate hunt for anomalous behavior. (210)

William Ryan has used the phrase blaming the victim to describe the ideologies and practices that have been used in the United States against deprived groups and individuals suspected of menacing law and order. This is how it works: „First, identify a social proble,. Secon, study those affected by the problem and discover in what ways they are different from the rest of us as a consequence of deprivation and injustice. Third, define the differences as the cause of the problem itself. Finally, of course, assign a government bureaucrat to invent a humanitarian action program to correct the difference.“ (210-211)

If we are right in thinking that we are now witnessing a transition to a new and more effective level of technological manipulation of marginal social groups, hten criticism of social control policies must also shift its ground to focus on the manipulative uses of the „scientific“ approach. (213)

 

Chapter 8: Psy Services and Their New Consumers

One comes away with an impression that everyday life is utterly suffused with interpretations stemming from medical psychology; the methods are now so flexible that nothing further stands in the way of their unlimited proliferation. The political implications of this colonization of social life by psychology are enormous. (257)

The same society that welcomed Freud as the messiah continues to celebrate his lesser epigones. Why? Because the role that psychoanalysis played in the United States was not limited to dominating, as it once did, the narrow field of mental medicine. Psychonanalysis was the main instrument for the reduction of social issues in general to questions of psychology. (261-262)

With the arrival of the post-psychoanalytic era it has become possible to speak of „therapy for the normal“ on a much wider scale. This is an important change, for it implies that anyone and everyone now falls within the purview of one of the new types of therapy. (264)

[…] behavior modification has been used as a way of imposing scientifically designed controls on the daily routine of many people; it therefore lends itself to a virtually unlimited range of applications. With some exaggeration, perhaps, it might be said that behavior modification turns all of life into an educational and disciplinary institution. (266)

„Therapy for the normal“, then, uses an array of mental and, particularly, physical tehcniques to maximize the „human yield“ of each individual; it is not aimed at healing, as standard therapies presumably are. The goal is not to get well, but to become healthier (that is to experience more pleasure, to „get in touch with one’s feelings“, to become aware of one’s body, etc.). Medical healing gives way to personality growth: Encounter groups are designed for people who are functioning normally but who wish to impove their relationships with others. (282)

To earn the right to treatent (as psychoanalysis had suspected), the normal individual must exhibit neurotic symptoms. But what is a symptom? „A psychic symptom today is no longer a symptom but a sign that life lacks joy.“ Normal life – social life – is sick, it requires therapy, therapy for nomrality, and techniques to develop human potential and foster autonomy and enhance pleasure in a sad and alienated world. Adjustment, then, has been supplanted by a normative notion of normality – normality seen, in this new light, as the product of „working on“ one’s own personality. (282-283)

If a man’s social status is merely a product of the way he lives his life, then it is possible to use technical means to manipulate the factors that enter into his choices. With regard to relations between social groups, this outlook has led unions, for wxample, to take a particular line, namely, to make demands aimed at enabling the category of worker they represent to „play the game“ successfully within the system, i.e., to compete successfully in the struggle for advancement. With regard to the lowest strata in the society, it has led to a welfare policy that seeks to minister to individual shortcomings without touching the structural conditions that may be responsible for them (293)

What is being worked out, in short, is a completely rational concept of man, a concept perfectly attuned to the dominant notion of what is rational. The problem then ceases to be one of healing the sick, reeducating the guilty, ot controlling deviant behavior (these goals remain, of course, but as objectives allied with new techniques). Instead, „normal“ man has come to the fore as the center of attention in a society whose only passion is to produce earnestly and efficiently. To heal is good, to precent is better, but to maximize output by adjusting each individual to his social role and by calibrating change to the social dynamic as required by the necessity to reproduce the social order is surely the ideal of policy without politics. (295)

 

Conclusion

Underlying the boldest attempts to standardize behavior is a conception of a sort of „scientific“ utopia: to achieve happiness for both the individual and the community by means of rational planning carried out by technical experts. (316)

If the study of recent changes in psychiatry proves anything, it is how much the present expansion of psychiatry’s sphere of influence owes to those who have come one after another to work on the fringes of the profession, pushing back its boundaries by „moving beyond“the old models, which they descrube as archaic, coercive, prescriptive, and so forth. (319-320)

Psychiactric sociaty: No longer a society in which psychiatry takes care of a few patients, whether really ill or merely purported to be, in any case defined bu a starky contrast between the normal and the pathological; but rather an organization of everyday life in which manipulative techniques, more often than not developed and popularized mental medicine, become coextensive with all aspects of social life. No longer the manifestation of naked power exerted directly to repress social and political differences; but rather diffuse pressures of many kinds, which invalidate such differences by interpreting them as so many symptoms to be treated. Not the country of gray dawns in which state commissars drag dissidents out of bed at the crow of the cock; but rather a padded world watched over night and day by squads of skilled specialists, many of them well-meaning. Skilled at what? At manipulating people to accept the constraints of society. (320)

Howard Markel & Alexandra Minna Stern “The Foreignness of Germs”

Markel, Howard; Alexandra Minna Stern 2002. The Foreignness of Germs: The Persistent Association of Immigrants and Disease in American Society. The Milbank Quarterly 80(4): 757-788.

 

Racial Labels and Medical Exclusion, 1880–1924

First, the rise of bacteriology, which for the first time in human history identified microscopic organisms as the culprits of specific diseases, galvanized existing public health programs and encouraged med-ical authorities to believe that germs could be contained and controlled through direct intervention (Leavitt 1996). (761)

Second, during a period in which evolutionary doctrines upheld a belief in the racial degeneracy of most nonwhite groups, it was relatively easy to attribute the weary condition of some immigrants—whether impoverished, malnourished, or suffering from a particular ailment—to their biological inferiority. (761)

Third, the broader medical surveillance of immigrants was part and parcel of a more overarching expansion of the federal government that entailed the subsumption of local and state public health agencies by the United States Public Health Service (USPHS) (Marcus 1979). (761)

 

Illegal Aliens and Anti-communism, 1925-1964

After the passage of the 1924 National Origins Act and its more carefully articulated interpretations in 1927 and 1929, the rhetoric of the biological hierarchy of races trumped all other medicalized rationales for shutting the doors to the foreign born. These laws favored immigrants whose external physical appearance most resembled the majority of white American faces and were believed to possess the greatest potential for assimilation into mainstream society. (767-768)

In McCarran’s anti-immigration rhetoric against east European Jews, southern Italians, Asians, and other so-called undesirables were deep-seated metaphors of disease and contagion. As floor manager of the bill during its final debate in the Senate in mid-May 1952, McCarran made an impassioned plea to save the United States from imported ruin: „Today … as never before, a sound immigration and naturalizationsystem is essential to the preservation of our way of life, because that system is the conduit through which a stream of humanity flows intothe fabric of our society. If that stream is healthy, the impact on oursociety is salutary; but if that stream is polluted our institutions andour way of life becomes infected.“ (Congressional Record, May 13, 1952, 5089) (773)

For example, in the law’s general categories of ineligible aliens, we find—in no explainable order of actual threat—the feeble-minded; the insane; people with epilepsy or other mental defects; drug addicts and alcoholics; those with leprosy or contagious diseases; aliens found to have a physical defect, disease, or disability that would restrict their ability to earn a living; the impoverished; criminals; polygamists; prostitutes; homosexuals; contract laborers; and Communists, anarchists, or those subscribing to totalitarian political ideologies (U.S. Immigra-tion and Nationality Act of 1952). (774)

Despite the presidential warning, Truman’s veto was overridden, and the bill became law on June 27, 1952 (Congressional Record, June 26–27, 1952). Although from this moment on, American presidents—from Truman and Eisenhower to John F. Kennedy—began advocating a more liberal and fair-minded immigration policy, this did not become a reality until Lyndon Johnson signed the Hart-Celler Immigration Act of 1965. (774)

 

The Newest Immigrants and the Recrudescence of Old Fears, 1965-Present

In the context of resurgent anti-immigrant sentiment in the 1980s, calls to protect the public health from external hazards began to be sounded in tandem with the escalating AIDS epidemic. For example, in 1986, the USPHS suggested adding AIDS to the list of infections that would automatically debar a prospective newcomer. (777)

The AIDS regulations reiterated a recurrent theme in American immigration policy, that specific “undesirable” groups were labeled as being “high risk” whether or not they actually posed a threat of transmitting disease. (778)

[…] in February 1993, Senator Don Nickles of Oklahoma introduced a bill prohibiting the entry of HIV-positive immigrants on economic grounds, which passed in the U.S. Senate, 76 to 23, with an even larger show of support in the U.S. House of Representatives a few weeks later. (779)

On June 10, 1993, President Bill Clinton signed into law the National Institutes of Health Revitalization Act, which amended the Immigration and Nationality Act of 1988, adding HIV infection as a criterion to keep out immigrants. […] Known colloquially as “Proposition 187,” this state law required publicly funded health care facilities to refuse care to illegal immigrants and mandated that health care workers who suspected that one of their patients might be an illegal alien report him or her to the Immigration and Naturalization Service, the state attorney general, and the state director of health services (Ziv and Lo 1995). (779)

Some recent studies of the public health risks of tuberculosis around the world recommend that instead of forcing undocumented immigrants to hide from physicians, the United States and other industrialized nations create user-friendly tuberculosis detection and treatment programs for the hundreds of millions of people who cross international boundaries each year (Bloom 2002; Bloom et al.

1999; Farmer 1999; Geng et al. 2002; Reichman 2002; Sachs 2002). Such an arrangement was recently implemented by the U.S.-Mexican Border Health Commission to track and care for Mexican transmigrants afflicted with HIV/AIDS, hepatitis A, or tuberculosis (Smith 2001). Especially novel is the creation of a confidential binational tuberculosis card that allows patients to obtain treatment in both the United States and Mexico without fearing deportation or long-term detention in one of the many TB screening centers along the border (Sachs 2000). (780)

 

At many points over the past century, some people have wanted to exclude persons perceived as foreign, inassimilable, and dangerous to the country’s social, political, or economic fabric. Metaphors of germs and contagion have never lurked far beneath the surface of such rationales. As we have shown, more often than not these arguments have been motivated by, and closely intertwined with, ideologies of racialism, nativism, and national security rather than substantiated epidemiological or medical observations. (780-781)

If any concept in this brief history of immigration and public health is antiquated, it is the idea that infec-tious diseases can be controlled by targeting certain populations based on apparent ethnic or national background. (781)

M. Gagnon, J.D. Daniel, A. Guta “Treatment Adherence Redefined”

Gagnon, Marilou; Jacob, Jean Daniel; Guta, Adrian 2012. Treatmend adherence redefined: a critical analysis of technotherapeutics. – Nursing Inquiry (Epub ahead of print).

The development and implementa-tion of technotherapeutics are suggestive of particular tactics of governmentality that concern issues of individual conduct (i.e., treatment adherence), which are also known to inter-fere with the production of a healthy population. (2)

Direct methods may include direct observation by healthcare pro-viders (i.e., pharmacist) or objective measurements of drug concentrations in blood or urine. Thus, these methods not only require the presence of a healthcare provider who will record treatment adherence, but imply that individuals who deviate from the prescribed treatment will be automatically identified. In this sense, direct methods allow for healthcare providers to keep track of adherence via objective measure-ments (i.e., number of visits at the pharmacy, number of pills taken, and serum concentration) and intervene directly when individuals fail to take their treatment as prescribed. (3)

Recent advancements in technology now enable healthcare providers (and researchers) to monitor adherence indirectly via an electronic system capable of recording, for example, when medication bottles are opened (smart pill bottles) or when pumps are activated. Indirect methods such as this one have created new possibilities for healthcare providers to objectively monitor adherence at a distance and intervene directly when individuals fail to take their treatment as prescribed. (3)

By adding a digestible sensor to a standard pill capsule, the sensor undergoes an activation process within the stomach fluids and sends digital signals to the implantable microchip located under the skin of individuals who undergo prolonged treatments. For Proteus Biomedical, this device offers significant advantages for healthcare providers because it is capable of tracking the date and time of pill ingestion, recording drug-related information (i.e., type, dose, and place of manufacture), and measuring physiological parameters (heart rate, blood pres-sure, weight, blood glucose, body temperature, and respira-tory rate). This prototype is set to record information, generate feedback in real time for those involved in adher-ence work (including healthcare providers, patients, family members, and relatives), and promptly signal when a treat-ment is not being taken as prescribed. (3)

We will examine how this instrument of surveillance is, in fact, an anatomo-political instrument that exerts a hold over individual bodies and reconfigures individual behaviors in accordance with a pre-determined set of clinical objec-tives. (3-4)

By adherence work, we mean the broad range of activities through which healthcare providers, family members, rela-tives, and patients themselves look after treatment uptake to achieve optimal clinical outcomes. What becomes evident is that the need to closely monitor treatment adherence, and ensure those who deviate from the prescribed treatment are identified in a timely fashion, has led to the development of a new panoptic machine. (5)

Here, it is important to recognize that the efficiency of the panop-tic machine can be explained by the fact that surveillance not only makes individuals aware that they are being watched, but it makes them engage in self-surveillance during times of deviance; or, before misconducts or faults (such as non-adherence) even take place (Holmes 2001). (5)

Theideahereistousethisnewandpreviously unavailable knowledge to sanction individuals who demon-strate poor adherence while validating those performances that meet expectations. From this perspective, it is believed that individuals will be motivated to adopt prescribed con-ducts, habits, and attitudes when they are confronted with their performance (optimal or not) and positioned in rela-tion to the norm. (5)

Bio-politics, explains Foucault (1990), is closely tied to surveillance and the production of knowledge about pop-ulations. In fact, the birth of bio-politics is said to coincide with the introduction of new techniques to study and closely monitor biological occurrences at the population level (Fou-cault 1990). (6)

Bio-politics stands for the administration of life as a col-lective reality (Lemke 2011) and the management of issues known to interfere with life processes. It is concerned with issues that can be documented, measured, and aggregated on the level of populations – but, also, with calculations of possible and probable risks (Gordon 1991). To this end, bio-political interventions take on the semblance of solutions to discrepancies uncovered in the process of gathering infor-mation about populations or in the process of calculating risks within the collective body. (6)

We locate the development and growth of technotherapeutics at the intersections of bio-politics, and what Clarke et al. (2003) have termed biomedicalization. (7)

[Biomedicalization] …is characterized by its greater organizational and institu-tional reach through the meso-level innovations made possible by computer and information sciences in clinical and scientific settings, including computer-based research and record-keeping. The scope of bio-medicalization processes is thus much broader, and includes conceptual and clinical expansions through the commodification of health, the elaboration of risk and surveillance, and innovative clinical applications of drugs, diagnostic tests, and treatment proce-dures (Clarke et al. 2003, 165). Clarke AE, JK Shim, L Mamo, JR Fosket and JR Fishman. 2003. Biomedicalization: Technoscientific transforma-tions of health, illness, and U.S. biomedicine. American Sociological Review 68: 161–194. (7)

Tech-notherapeutics brings together three major forms of risk identified in neoliberal societies; insurance risk, epidemio-logical risk, and case management (Dean 2010). These three conceptions of risk are less concerned with individual adher-ence than with managing shared health costs, the spread of disease, and keeping individuals who pose a risk connected to regulatory systems. Risk assessment is no longer an indi-vidual matter, but now accounts for whole groups and their practices, and the social risk they pose in relation to health and disease, life and death. (7)

Overall, we understand technotherapeutics as serving to both disci-pline individual bodies and also to regulate whole groups of people deemed to constitute a threat to the collective body. In this sense, we consider that adherence work is above all a political project that endeavors to achieve optimal disease management (through surveillance and discipline), reduce the financial burden of treatment non-adherence on health-care systems, and serve to further marginalize and differenti-ate ‘at-risk groups’ because of their unwillingness or inability to conform. (7)

Returning to the bio-political goal of ‘making live’ and ‘letting die’, we understand that the populations deemed ‘hard to reach’ and ‘vulnerable’ – gay and other men who have sex with men, sex workers, injection drug users, and aboriginal people – have been historically constructed as ‘risky’ and dangerous. In this particular context, technotherapeutics would allow for healthcare providers to gather previously unavailable information about these populations and use this information to intervene directly with patients who deviate from prescribed treatments; not for theirbenefit,but to make sure they do not affect those who the state would ‘make live’ (otherwise useful and productive bodies). (8)

On one hand, technotherapeu-tics are being introduced under the premise that they can improve the therapeutic management of chronic conditions, maximize clinical outcomes, facilitate communication with healthcare providers, and individualize the care provided to those who undergo prolonged treatments. (9)

On the other hand, the development and implementation of technothera-peutics suggest particular tactics of governmentality that can-not be overlooked. (9)

Stuart J. Murray “Care and the self”

Murray, Stuart J. 2007. Care and the self: biotechnology, reproduction, and the good life. – Philosophy, Ethics, and Humanities in Medicine 2:6. available: http://www.peh-med.com/content/2/1/6

To “examine” one’s life today is to submit to medical knowledge and techniques, to evaluations, and to normalizing judge-ments. It is to be governed by so-called experts, and to be understood in and through recent genomic and molecular vocabularies of biomedicine.

Medical discourse thus informs one manner in which the self or subject is constituted – and silently comes effec-tively to constitute itself as a subject. In this sense, medi-cine operates as a “technology of the self,” a nexus of social, political, and historical practices and beliefs that provide the very terms of the self and its self-understand-ing.

What Foucault famously called the “clinical gaze” is fast being sup-planted by the “molecular gaze” [4]; biopolitics – a poli-tics concerned with the life of the population – is being supplanted by “molecular politics” [5].

I argue that human identity is fast becoming a mat-ter of genomics, the identity of the self collapsed into its genetic identity.

[…] two sharply contrasting models of “care.” The first I call “self-care,” a model that has dominated public health policy in recent years. “Self-care” relies on a model of selfhood that is drawn from the tradition of lib-eral humanism: the Enlightened, knowing self, the self that is conceived as the source of its own agency, autono-mous, free, and guided by conceptual reason. This is the self that medical ethics typically presumes as founda-tional: rational, autonomous, and freely able to consent. […] In contradistinction, I shall pro-pose a second model of care that I borrow from Foucault’s ethics – “care of the self.” I hope to show how the Foucaultian “care of the self” is incommensurate with the care that we find in the “self-care” paradigm.

[…] while for the Greeks, the question was how to live and live well, for Rome – and for us – life is no longer the “ethical substance” or the fundamental question, but selfhood is that substance.

Today, medicine has become part of the  problem  of the self, and this becomes even more obvious in our genomic era of medi-cine: who or what am I if I am first and foremost a genetic self; what ethico-political responsibilities do I have to myself, to others, and to my offspring within this para-digm; and what subjective agency is left to me if the sov-ereignty of the Kantian “I” is displaced from a rational, autonomous self onto a sovereign genetic code that has the first and last word on who I am, what I am, and on who and what I shall become? These are the new problems of the self in a genocentric age.

Responsibility is conceived in economic or entrepreneurial terms [5,15,19]: I, as a patient, am treated foremost as a client who employs expert-providers in my own health care initiatives, to improve my health, to work on my self as if I were not the subject of my own well-being but an object in need of repair or enhancement. Here, the self-self relation is explicitly technologized, instrumentalized. The self relates to itself as through a knowledge economy – I am respon-sible to “know” my self biomedically, to take decisions and perform “best practice” actions in the project of my own well-being […]

This emphasis on the autonomous individual effec-tively privatizes and depoliticizes what are properly social and political effects, embodied historical effects whose operational power is summarily masked and disavowed by liberalism.

I prefer to imagine the “care of the self” as a self-self relation that is inventive and open, as a self that questions the norms and constraints in and by which that self is said to be a self in the first place.

So to repeat, the spiritual relation the self has to itself will inform epistemological truths and falsities, not the other way around – epistemology is not the founda-tion of the self, as it has been since Descartes. This turns modern Western philosophy and politics upside down.

So we can see that care is a relation that is directed both within and without. It is an ethical relation because it has everything to do with one’s ethos, with the way one lives one’s life and conducts oneself with respect to oneself, to others, and to the world in general. It is about the good life, not the good self.

The self relates to itself non-foundationally, non-substantially, and in this respect, we might be justified to invoke Socra-tes when he speaks of the “soul.” The soul or “psyche” is dynamic and without substance; it is neither body nor mind, as these terms are traditionally understood; it is nei-ther cognitive nor conceptual. Instead, we might call it a rhetorical device for plotting the relation between the self and itself, which includes the relation between the self and the other whose love and wisdom helps to bring that self into a caring proximity with itself.

[…] I fear that increased choice in, say, the genetic marketplace may prove detrimental to truly progressive social and political projects. Ultimately, a proliferation of choices in the genetic marketplace will not unequivocally result in greater social and political diversity, but may instead result in more stringent norms, less diversity, and greater intolerance of all forms of difference, genetic and otherwise.

But by the “care of the self,” Foucault helps us to depart from this normativity. For him, care is a way of being-in-the-world, an attitude, a chiasmatic rela-tion that constitutes the individual and the institution as two separate poles whose positions rely on dynamic power relations and norms that ought to be critiqued. Sev-enhuijsen and Tronto erroneously start by presuming the givenness of individual selves and institutions responsible for our care; this is the model of “self-care” as I have defined it. In contradistinction, Foucault does not pre-sume such a givenness.

Michel Foucault “The Politics of Health in the 18th Century”

Foucault, Michel 2000. The Politics of Health in the Eighteenth Century. – Foucault, Michel. Power. Essential Works of Foucault, Volume 3. New York: The New Press: 90-105.

An analysis of idleness—and its conditions and effects—tends to replace the somewhat global charitable sacralization of “the poor.” This anal-ysis has as its practical objective at best to make poverty useful by fixing it to the apparatus of production, at worst to lighten as much as possible the burden it imposes on the rest of society. The prob-lem is to set the “able-bodied” poor to work and transform them into a useful labor force; but it is also to assure the self-financing by the poor themselves of the cost of their sickness and temporary or permanent incapacitation, and further to make profitable in the short or long term the education of orphans and foundlings. Thus, a complete utilitarian decomposition of poverty is marked out, and the specific problem of the sickness of the poor begins to figure in the relationship of the imperatives of labor to the needs of produc-tion. (93)

Down to the end of the ancien regime, the term “police” does not signify (at least not exclusively) the institution of police in the modern sense; “police” is the ensemble of mechanisms serving to ensure order, the properly channeled growth of wealth, and the conditions of preservation of health “in general.” (94)

The medical politics outlined in the eighteenth century in all Eu-ropean countries has as its first effect the organization of the family or, rather, the family-children complex, as the first and most im-portant instance for the medicalization of individuals. The family is assigned a linking role between general objectives regarding the good health of the social body and individuals’ desire or need for care. This enables a “private” ethic of good health as the reciprocal duty of parents and children to be articulated onto a collective sys-tem of hygiene and scientific technics of cure made available to individual and family demand by a professional corps of doctors qualified and, as it were , recommended by the state. (98)

The city with its principal spatial var-iables appears as a medicalizable object. Whereas the medical to-pographies of regions analyze climatic and geological conditions outside human control, and can only recommend measures of cor-rection and compensation, the urban topographies outline, in neg-ative at least, the general principles of a concerted urban policy. During the eighteenth century the idea of the pathogenic city in-spires a whole mythology and very real states of popular panic (the Charnel House of the Innocents in Paris was one of these high places of fear); it also gave rise to a medical discourse on urban morbidity and the placing under surveillance of a whole range of urban developments, constructions, and institutions. (99)

A “medico-administrative” knowledge begins to develop concerning society, its health and sickness, its conditions of life, housing and habits; this serves as the basic core for the “social economy” and sociology of the nineteenth century. And there is likewise constituted a politico-medical hold on a population hedged in by a whole series of prescriptions relating not only to disease but to general forms of existence and behavior (food and drink, sexuality and fecundity, clothing and the layout of living space). (100)

The point is that, in relation to these new problems, the hospital appears as an obsolete structure in many respects. A fragment of space closed in on itself, a place of internment of men and diseases, its ceremonious but inept architecture multiplying the ills in its in-terior without preventing their outward diffusion, the hospital is more the seat of death for the cities where it is sited than a thera-peutic agent for the population as a whole. (101)

However, the disappearance of the hospital was never more than the vanish-ing point of a Utopian perspective. The real work lay in the effort to elaborate a complex system of functions in which the hospital comes to have a specialized role relative to the family (now con-sidered as the primary instance of health), to the extensive and continuous network of medical personnel, and to the administrative control of the population. It is within this complex framework of policies that the reform of the hospitals is attempted. (103)

It is also necessary to organize the internal space of the hospital so as to make it medically efficacious, a place no longer of assis-tance but of therapeutic action. The hospital must function as a “curing machine.” First, in a negative way: all the factors that make the hospital dangerous for its occupants must be suppressed, solv-ing the problem of the circulation of air (which must be constantly renewed without its miasmas or mephitic qualities being carried from one patient to another), and solving as well the problem of the changing, transport, and laundering of bed linen. Second, in a positive way, the space of the hospital must be organized according to a concerted therapeutic strategy, through the uninterrupted pres-ence and hierarchical prerogatives of doctors, through systems of observation, notation, and record-taking. […]The hospital tends toward becoming an essen-tial element in medical technology, not simply as a place for curing, but as an instrument which, for a certain number of serious cases, makes curing possible. (103-104)

Consequently, it becomes necessary in the hospital to articulate medical knowledge with therapeutic efficiency. In the eighteenth century, specialized hospitals emerge. (104)

Finally, the hospital must serve as the supporting structure for the permanent staffing of the population by medical personnel. Both for economic and medical reasons, it must be possible to make the passage from treatment at home to a hospital regime. (104)