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InSicknessandInHealth:Governingtheselfinthehospitalandtheclinic
Victoria,BC,Canada,April2009
Care&PatienthoodintheEraoftheGene
Dr Joanna Latimer, Professor of Sociology, Cardiff University School of Social
Sciences
PlenaryTalk
WhatIamgoingtodointhispaperisthinkthroughthecontemporarylandscapeof
health care, orwhatAdele Clarke calls a healthscape, one thatmakes explicit the
problemsandtheissuesforcareinafrankandprovocativeway.WithFoucaultIam
goingtofocusonsomeeffects.Theseeffectsmaybeintermittentintheiroperation,
but they are, I suggest, systematic and systemic because they extrude so may
possibilities:toomanybody‐personsseem,likedirt,tohavebecomeoutofplacein
themodes of ordering I am about to describe. And asMaryDouglas helps us to
understand,wherethereisdirtthereissystem.
OnmentioningthatIamgoingtogiveapaperoncare&patienthoodintheEraof
theGenecolleaguesinnursinghaverespondedwith–‘Ohwearenotteachingany
of thatyet’. But I amnotgoing to talkabout that–nursingcareknowledgeand
know‐howinthecontextofadvancesinbiotechno‐sciences.RatherIwanttothink
aboutwhathasbeenhappeningtocare inmedicinemoregenerally,andwhatthe
connectionsarebetweentransformationsincareandtheextraordinaryexplosionof
interestandresearchinthegeneticandbiologicalbasesofdiseasesandotherbodily
troubles.
So my talk here today in part draws out of and on from my many studies of
medicine, nursing and health care organization, including those with many
colleaguesandwithmyPhDstudents.ButitalsodrawsoutofwhatIhavecalledin
JayGubriumandJimHostein’sHandbookofConstructionistResearch,anemergent
critical tradition inresearchonmedicine,nursingandhealthcareorganization. As
such I do not speak so much as an individual but out of and as a part of this
emergenttradition,someofwhosefoundingauthorsareheretoday:CarlMay,Mary
EllenPurkis,TrudyRudge,SiobhanNelson,MaxineMueller.
Soletusthinkaboutthescaleoftheeffect.WhenIwasapractisingWardSisterin
the mid 1980’s at the Edinburgh Royal Infirmary, the clinical home of a world‐
renownedBritishMedicalSchool,no‐onethatIcanremember,andIwasincharge
ofaprofessorialwardwithallmyconsultantsdoublingupasclinicalscientists,ever
discussed the gene, or the molecular origins of any particular disorder. The
exception was a haematologist whose research specialism was the hereditary
conditionhaemophilia. Now,wherever I look, thegene,andothermicrobiological
processes are being explored for their involvement in pathology, and for their
potential in relation tomedical interventions.This isparticularly, ifnotexclusively,
true of the degenerative and chronic diseases of Euro‐American countries, the
diseasesofthewealthy,suchasdementia,thecancers,andsoon.Evenageingitself
asamicro‐biophysiologicalprocessisbeingreconsideredmoreandmoreasa‘part
of the problem’, and as playing an important role in the aetiology of many
pathologies.Maybesoonitwillevenbepossibletoputonadeathcertificatethat
someonehasdiedofoldage.Thisrepresentsahugeshiftformedicine:20yearsago
no‐onecouldbeseentodieofoldage,itwasn’tconsideredapathologyinitsown
right.
I want to think then about this huge shift, what some have described as the
biomedicalization or genetiziation of the clinic, for its significance, particularly in
relationtocare.
TheCurecareBinary
Letmebeginwithsomething I thinkyouwillall recognise. Akeydiscoursewithin
thelandscapeofmedicinerevolvesaroundthetropesofcureandcare.Inparticular
whatIwanttopointtohereisthe‘carecure’binary.
Figure1
Iamusingthetermbinaryverydeliberatelyhere.ThetermbinaryisfromtheLatin
binarius,meaninghavingtwoparts.Abinaryisthuscharacterizedbyorconsistsof
two parts or components; a ‘twofold’. I like this idea of a two fold because it
connects toDeleuze’s conceptualizationof the fold, andhowweare folded
intodifferentdiscoursesandtruthregimes.Abinaryisdifferentfromapolarity
or dualism – a binary implies connection and interdependence: critically, a binary
impliesrelationality. Forexample,abinarystar(Figure1) isasystemoftwostars
thatrevolvearoundeachotherundertheirmutualgravitation.Soratherthancare
andcurebeingunderstoodasadualism,wecanthinkofitasarelationthatworks
institutionallyaswellasdiscursively.
Thebinary ‘curecare’ thus helps informa set of practices thatwe canunderstand
looselyas‘medical’,andthatcirculatearoundthebody,themind,andmattersoflife
and death. In many ways this working between carecure offers a way to travel
acrossandbringintoplaythelife‐worldsofpatientsandofpractitioners.
Socareandcurecanbeunderstoodastwomajortropes,tropes incirculationand
thatcouldbereachedforandthathavethepowerto‘call’.WithFoucaultIwantto
stresshow it is the verymysteriousness andelusivenessof these terms, and their
relation, that gives them their potency – and that this binary relation of care and
cure,has importantorganizingeffects. This includesmaking itmuchmoredifficult
tosaypreciselywhereadivisionoflabourlies.LetmeelaboratewhatImeanhere:
2stories1ststoryI am just tidying up at the desk having taken the handover form the nightnurses. It is about 8 am when Ms Sparrow arrives to visit her post‐oppatientsfromyesterday. Igoovertojoinheratthebedsideofonepatientwho has had a pneumonectomy. Miss Sparrow kneels down on the floornext to the patients chest drain, stands up and tell s me it has beenincorrectly setup,with theendof thedrainage tube sitting just above thewaterlevel,thusallowingthepossibilityofairtoenteringthepleuralspace.Sheisfurious,amImortified.Iapologiseprofuselyandarrangeforthedrainto be changed immediately. As well as ensuring that the night staff areretrainedwithregardtochestdraincareImakesurethatinfutureontakingthehandoverfromthenightstaff, thenurse inchargeandthenightnursecheckallthechestdrainstogether.(Lifestoriesofalapsednurse,Latimer,inprocess).2ndstoryIt isProfessorPetrie’sward roundandwe travel frompatient topatient inthe usual way. We arrive at the bedside of a very frail elderly lady, MrsGallacher, admitted with collapse, heart failure and severe anaemia. Thehouse doctor has presented a history of the patient in the doctor’s roomprior tocomingonto theward.Fromthemedicalhistory thepatient isnotapparently on any anti‐inflammatory medication. I have not met MrsGallacherbeforeasIhaveonlyjustcomebackfromsomedaysoff.Isitdownnext toherandtakeherhandwhile thedoctorsaretalkingtoher. Inoticethatshehasveryarthritichands,swollenandred.Iaskherifshetakesanythingforthepain.Shesaysshetakeslotsofaspirin.ProfessorPetrieordersa barium meal. Of course, Mrs Gallacher probably has not thought thataspirinisamedication.(Lifestoriesofalapsednurse,Latimer,inprocess).
Figure2
Inthesetwomundaneordinarystories(Figure2),whoisdoingthecaringandwhois
doingthecuring–thedoctororthenurses?Eachactionslipsandslidesacrossand
betweenthebinarycarecure.
So I want to clarify that within this perspective of the binary curecare, medicine
emergesasall thepractisesandprocesses,peopleand technology involved in the
performance ofmedicine: medicine appears as distributed across many kinds of
practitioner, including nurses and doctors, physios, radiologists, and so on and so
forth.
WecanthinkofthebinarycurecareintermsofaMöbiusstripi(Figure3).AMöbius
strip ismadebytakingastripofpaper, twisting itonceand joiningtheends.Now
the strip has only one side and one edge. This can be demonstrated by putting a
pencil down on the strip, turning the strip under the pencil until the pencil line
returns to its starting place. Thepencil linewill appear onboth sides of the strip,
whichmeans, in effect, that it hasonlyone side. In the carecurebinary, care and
curetravelalongplanesthatendupasconnectedandonthesameside.
Figure3
As we have seen from my two stories there are possibilities for chiasms and
crossingshere.Theambiguityandambivalenceoverwhatcountsascuringorcaring,
allows forgreatmotility andkeepsopenpossibilities for shifts inperspectivesand
justifications.Forexample,howanactivityconstitutedascarecansoeasilyalsobe
seentohaveotherpotentialintermsofcure.
Figure4
Forexample, in figure4according to the titleof the image, amanwith leprosy is
weavingasapartofhiscarefollowinghiscure.Butofcoursefromtheperspective
ofoccupationaltherapy,occupationintheformofweavingitselfhasaffectsinterms
ofenhancingwell‐being.Weavinginthiscontextisinasensecurative.
NowofcourseIamofferingthebinary‘curecare’asinasenseanidealtype,butone
thathasitsorganizingeffects.ItisoneIthinkthatevenifwedon’tlongforit,weat
leastrecogniseit.
Therehavealwaysbeenproblemsforcarewhereabody‐personcannotbeheldon
the medical ground of cure, where they can be figured as Becker’s ‘crocks’, or
Jeffrey’s‘normalrubbish’:aspeopleforwhomnothingcanbedone,astrivia,oras
havingaswhatonenurseinoneofmystudiescalled‘noprospectaheadofthem’.
DameCiceley Saunder’s hospicemovement in the1980’s and IngunnMoser’s talk
yesterdayaboutdementiacare,andwhatshecalled ‘a logicsofrehabilitation’,are
examples that help expose how any body‐person‘s ills can be subject to care
practicesthatcontainwithinthemapossibilityforenhancement.Howforsomany
bodytroubles,particularlyinrelationtothosederivingfromchronicillnesses,cureis
itself is an unobtainable ideal if too narrowly conceived. Critically, in the curecare
binaryevenwithaso‐calledincurablediseasesomeonecanhavealife,theycando
morethanmerelyexist,includingtheprocessofdyingbeingitselfapartofthatlife.
NowIwanttosuggestthatwecanreviewthelandscapeofsocialtransformationin
healthcaresystems intermsofdividingpracticesthathave insertedandworkeda
riftinthebinary‘curecare’,andthatundermineitsorganizingproperties.AndIwant
to suggest that thesedividingpracticesalignandoverlap toperformconditionsof
possibility for the chasm between cure and care that we are currently struggling
with.
DividingPractice1:MedicalDominance
ThefirstofthesedividingpracticesthatIwanttopointtoiswhathasbeentermed
in the literature ‘medical dominance’. What everyone knows and understands is
thatthroughprocessesofappropriationandclosurethetermmedicinehasbecome
reservedforwhatdoctorsdo.
Here then the two entirely mysterious conceptions, care and cure, in a binary
relationtooneanother,throughthedividingpracticeofmedicalprofessionalization
begintobecomeseparated,disconnected.Specifically, inthereservingoftheterm
‘medicine’forwhatdoctorsdothereisasubsequentdivisionbetweencurativeand
caringpractices,betweencur‐iosityandcarefullness.
WecanseeinFoucault’sBirthoftheClinicthattheemphasisonknowledgeandthe
performanceofmedicineas sciencepushesandpresses thisdividingworkof care
fromcure,so thatcurebecomestheprerogativeof thedoctors,whilecareat first
seemstoberelegatedtothe‘para’‐medicals,particularlytonurses.Andinparticular
there is a possibility of making it seem that there is a separation of the work of
representing(assayingwhatis)fromtheworkofinterveningandtreatment,aswell
asfromtheworkofcaring.
And thisdivisionbetweencareand cure canbeplayedacrossotherdivisions. The
divisionofferedtousbyMikeFeatherstone(1992),forexample,betweentheheroic
and the mundane, with cure being associated with the heroic life, while care
becomesassociatedwiththeeverydaylife. Andacrossotherdivisions:suchasthe
division between cure asmasculinework, and care as femininework; or across a
divisionbetweenwhatDrewLederdistinguishesastheobjectbody(corps),andthe
lived body (lieb), with the object body the concern of cure and the lived body as
relegatedtotheworkofcare.
But as Ann Marie Rafferty helps illuminate in her book The Politics of Nursing
Knowledge, these practices of care and cure divide particularly over the issue of
claimstoknowledgeandtheproblemofwhatcountsasknowledge.
Critically, what governs the space of medicine as cure, is knowledge as science:
science as of a particular kind, associated with the scientific method. And this
governing of the domain ofmedicine by knowledge as science,means that other
practitioners, such as nurses, tomake theirwork visible as professionalwork, are
called tomake explicit how their work is also knowledge based. Here there is a
proliferationofresearchintothe‘care’partofthe‘clinical’domain–pressurearea
care, wound treatment, infection control and so on and so forth. Within this
perspective and rendering, care begins to be reconstructed, and effaced, as
‘intervention’.
Whatismuchmoredifficultinthespaceofknowledgegovernedbyideasofscience
isresearchonthoseactivities,processes,effectsandaffectsthatareinvisibletothe
scientificmethod,thoseaspectsofthemedicalworldthatare invisibletoso‐called
‘normal’science.
Whereknowledgeassciencegovernstheorderingofrelationsofrepresentation,the
cliniccomestobeorganizedhierarchically,intheFoucauldiansense.Thuswhatwas
onceabinary,curecare,underthesekindsofdividingpracticesbeginstobeplayed
out in a hierarchical relation, relations of what Marilyn Strathern (1997) calls
comparison. So that care begins to emerge as the supplement of, or even as an
inferiorsubstitutefor,cure.Iamthinkinghereofallthosesituationsinwhichcure,
increasingly narrowly defined, is not possible, so that all that is possible is that a
condition ismanaged. Here,minimal caremayarrive in the formof adifferential
diagnosis. Butaswillbeseen inthenextsection, increasinglythemanagementof
conditions constituted as incurable (such as diabetes, asthma, dementia, arthritis,
andsoon) isbeingpassedontotechnologiesofcare,orwhatBrunoLatourwould
callmachines.
DividingPractise2:AccountabilityasTransparency
Iwanttoturnnowtothematterofaccountability,intheguiseoftransparency,and
thedividingpracticesofwhatStrathernandothershavecalledauditcultures.
Whatstartstoemergeinanalyseshereisthatmanagementsciencedoesnotbelieve
inknowledge in thesamewayaswehaveseenabove. Rather, Iwant tosuggest,
thatmanagerialismwantstochangecultures. Here,theneedtochangeculture in
the domains of care and cure, partly arises from the elision between culture and
tradition,ideologyandideasthattheprofessions,particularlydoctors,areorganized
along tribal lines: it is the ceremonial order of the clinic that is the drag on
modernizationofhealthcare.Managerialismthusfindsanalignmentwiththesocial
science critique of medical domination. We can see this in Phil Strong and Jane
Robinson’sanalysisoftheNHSundernewmanagement.
Now what I want to suggest is that because of the displacement and hierarchy
betweencureandcareeffectedthroughthedividingpracticesofmedicaldominance
discussed earlier, transparency over what has been set aside as curing has been
differentfromwhathasbeensetasideascaring.Thedividingpracticesthatwehave
alreadyencounteredthuscreatesanarchaeology,asetofseamsand foundations,
along which accountability travels to create further rifts and cracks in the binary
carecure.
Put under the microscope of transparency medicine, governed by knowledge as
sciencehas togooff somewhereelse– far fromthebedside– toreassert itself in
relationtoknowledgeasscience.Otherwiseitisonveryshakyground.
Herewe can imagine that the first space formedicine as cure to retreat to is the
technology of the Randomised Control Trial and evidence‐based medicine: here
everything to do with intervention can be trialled. But what trials don’t help
medicine‐as‐cure to do is perform itself as beyond the pale of ordinary
accountability,thatisasrepresenting,asengagedinnormalscience:RCT’sdonotdo
the work of making medicine‐as‐cure visible as science, as discovery, as ‘real’
science. As Ian Hacking’s work has helped to show, the strongest grounds for
legitimating the need for intervention are those routed through the mode of
orderingofferedbyrepresenting:onlywhenmedicinecanbeshowntobeengaged
in representing ‘what is’, as engaged in normal science can it make itself
(un)transparent,andfendoffcallstoaccount.
Somedicineascureneededtoperformitselfasrepresenting,not just intervening:
doingthiscanmakemedicineascure(un)transparent.Somedicineneededharder
sciencetothatofferedbyRCTandthetechnologyofevidencebasedmedicine.Itis
hereIwanttosuggestthatmedicinehasrealigneditselfwiththegeneandthenew
biology.
Myargumentisthenthatitisamanagerialneedforaccountabilityastransparency
thathassentmedicinebacktothebasicsciences:alignmentsbetweentheclinicand
the newmolecular and reproductive biology offers firmer ground formedicine to
make itself (un)transparent as knowledge. In its realignment with the basic
biosciences,andareturntobiomedicine,medicinereturnscuretothewell‐travelled
wayofscientificmethodornormalscience.
Letsstoptothinkforamomentherehowmucheasieritistoclaimrevelationinthe
laboratorythanintheclinic.Herethereispromise,orasothercommentatorshave
suggested,hope,notforpresentinterventions,butforafutureofknowledge.Bio‐
medicalknowledgepromisesnotjustafutureknowledgeoftheoriginsofillnessand
diseasebutofthestuffoflifeitself.
Whatthealignmentoftheclinicwiththenewbiomedicalsciencesdoesiseffectan
evenmoreintensereduction,asEmilyMartinhaselaborated,ofnotjustillnessand
itsorigins,butofpersons,toeversmallerbodyparts.Thisreductionisofcoursethe
seduction:becauseitfocusesonthestuffoflifethenewbiomedicinedrawsthegaze
awayfromthecomplexityandmessof,forexample,socialmedicine.Thisisnotjust
to recognise that there is also a complexuniverse there, at themolecular level of
interacting stuff, but this complexity and unravelling at the molecular level helps
perform biomedicine as mastering nature, and the universe within. And as
transparencyandthedemandsofauditculturedrivemedicinebacktoscience,there
isreinforcementandintensificationofknowledgeasnormalscience.
Back in the laboratory, medicine as biomedicine appears more real, and more
transparent.Andwithinthisview,theclinicandthebedsideitselfareakeypartof
thelaboratory,asIhaveshowninmyworkonclinicalgenetics.Butbackhereinthe
laboratory,weareinastateofanticipation,standingonceagaininwhatHeidegger
callsadvanceoftheworld.Andhere,inthelaboratory,cure,thrustintothefuture,
is amillionsmiles away from care. Butwhat for themoment seems to be being
accomplished is the rebirth of the clinic (Latimer et al 2006) as a site for the
productionnotjusttheconsumptionofknowledge.
Within this view accountability serves as a dividing practice so that we can
understandbiomedicalizationnotsomuchasacausebutaneffectofaccountability
regimescomingintotheclinic,regimesoftruththat intensifythedivisionbetween
cure and care, so that the fissures and rifts become chasms: abysmal rather than
chiasmic.
Sowhathappenshere–totheotherkindsofmedicalpractitionersassociatedwith
care,andthesick,ratherthancure,andtothepeoplewhoarehere,now,back in
thepresent?
NowifwerememberwithStrathernthatculture,inthecultureofenhancement,is
seenasadrag,andwithmedicalsociologistsandmanagerialists,thatitisinstitutions
such as medicine that are at fault, then what is needed under regimes of
accountability as transparency are technologies that can deliver interventions as
standardisedandmeasurable.Sothatbackhereinthedaytoday,ascurehasgone
off to RCT’s and the laboratory, care has become increasingly technologised,
demoralised,anddeskilled.
Accountantsandeconomistskeepsayinghowexpensivecareis,andhowwefacea
futureofmoreandmoreneedforcareaspopulationsage.Sotransparencycallsfor
carenottomakeitselfvisibleasknowledgebased,thisisthemistakeofnursingand
othercareassociateddisciplines.Rathercareneedstobemadevisibleasefficient,
sothatcaregetsreconfiguredasprovisionandintervention.Herethemanagement
ofcareisheavilyinvestedinthenotionofplanning–protocolsandproceduresthat
can stand in advance of their delivery, and a distribution of care work amongst
personswhoatthepointofdelivery,reconfiguredasproviders,aremerelyfollowing
ordersprescribedelsewhere.Stafffollowproceduresandimplementplans.Socare
is relegated to what Latour in his book Science in Action nominates asmachines.
Indeed, what care, reduced to provision and intervention, needs now are more
machines.
Careincreasinglydividedfromcureneedstomakeitselfvisibleagainstmeasuresof
efficiency specified far from the space of care. Within this context care,
reconfiguredasinterventionandprovision,canbeincreasinglytechnologised,made
leanandefficient,independentofthepractitionerswhodeliverit.HereIamthinking
thenthatwecanseetheeffectsofaccountabilityandtransparencyandthedivision
ofcare fromcure, intheendlessproliferationandpursuitof technologiestomake
caremanageable:suchascarepathwaysforspecificdiseasesortreatmentregimes,
thenursingprocess,collaborativecareplanningandsoonandsoforth.
Care reconfigured as provision and intervention has been taken over by the
machines:machinesthatcanbeunderstoodasprogrammesforconduct.Thereare
evenmachines that act as centres of calculation for theneed for care: scales and
assessmenttoolsforweightingtheneedforcare.Onesuchisthetriagesystem.
Caremachinessupposedlyobviatetheneedfordiscretion.Withinthisviewconduct
–that,hasasIhaveshowninmyearlierwork,hasamoralorspirituallinking–and
themysteryofcare–issidelined.
Moreandmoreofthisroutinisedmedicine‐as‐interventioncanbepassedontoGP’s
and nurses, while the work of providing for the body now almost completely
amputated from the work of cure gets passed on to paid and unpaid carers and
moreandmoretopatientsthemselves.GP’sandnursespickupmoreandmoreof
the medical work once it has been embedded in the machines as pathways,
proceduresandprotocols.Andcaregetsreconfiguredasillnessmanagement,with
interventiondistributedacrossmanydifferentagencies.Ontologically,practitioners
are refigured as providers and patients as recipients. Except of course patients
themselves are increasingly implicated in health carework, not just as carers, nor
even as CarlMay has shown in his studies of telecare, as recipients, butwith the
workofwhatonceusedtobeassociatedwithcure:theworkofmedicalexamination
anddiagnosis.Ratherthisseparationofcureandcare,ofdiagnosisfromintervention
and so on and so forth, and the proliferation of machines, has intensified and
proliferatedmomentsof assessment and access for patients and staff a like. And
thisthecripplingmess.
Fromtheperspectiveofpatientsthereisaproliferationofthresholds.Herepatients
cannotrelyonthemachines,medicalandadministrative,toactastheiralliesand
spokespersons, rather they are called to thework of negotiation and justification,
particularly in circumstances where their bodies and troubles do not fit the
configurationof thesystemsas they find them.Forexample,AlexandraHillman in
herworkonEmergencymedicineshowshowpatientsmustperformthemselvesas
carefulinrelationtohowtheyuseservicesandasneedingtohavetheresourcesto
mobiliseaccountsthatwillhelpnegotiatetheiraccesstocare.Withinthisrendering
apartofcureandcarepatientsgetrefiguredasthepotentialenemiesofthesystem,
whilethesystemitselfrequirescare.Butthereareotherinsidiouswaysinwhichthe
apparatusesofaccountabilityandtransparencyaretransformingpatienthood.
Patienthood:Thejointingofefficiencyandmorality
Strathern suggests that what audit cultures do is joint efficiency and morality.
Alongsidethereconfigurationanddemoralizationofprofessionalworkthecultureof
individuallivesathomehasbeenchargedtoavertoratleastpostponetheneedfor
care or cure. Here the exercise of choice comes into play as a site for the
performance of a particular kind ofmoral order, one that concerns itself, like the
genetics clinic, with a future of health andwellbeing. Remember, present action
aimedatthefutureisverydifficulttorendervisible.
Individualsarecalledtoperformthemselvesaschoosinghealth.Heretheyaremade
responsibleforhealthinrelationtoboththestuffoflifeaswellasthestyleoflife.
So that care shifted into the home, remerges as choice. On the one hand
transparencycallsforpeopletoperformthemselvesasgoodcitizenswherecareof
self involveschoosingastyleof life inanticipationofa lifeofhealth: livewellnow
andbehealthylater(figure5).
Figure5
Andontheotherhandthealignmentofthegeneandtheclinicconstructsandcalls
for people to exercise choice over the reproduction of healthy bodies andminds
(Latimer 2007) (figure 7). Of course choice here is always prefigured and
preordered:theneedforchoiceaswellasthepossibilitiesofwhatwemightchoose
areassociallyconstructedasanythingelsethatwemake.Here,thegeneticclinicis
asiteofsocialengineering:helpingtoexciteasenseoftheriskinessofreproduction.
Figure6
Fromchiasmtochasm:wheretonow
Themysteryofthecurecarebinaryseemstometobeincreasinglyinthedark.
Accountabilityastransparencyinsertsthenewrationalismintopracticesofcareand
cure in ways that operate along the fracturing already engendered through the
dividing practices of medical professionalization and dominance. Transparency
intensifiesthetrajectoryofcureandmedicinetowardsbiomedicalization.Sothereis
genealogy here on how managing through notions of accountability come in on
existingdivisionsaroundknowledge,andthedivisionbetweenmedicineandother
practices.
Biomedicalization within this perspective is an effect of regimes of accountability
andtransparencythathavedrivemedicinebacktothelaboratoryandamillionmiles
awayfromcare.Atthesametimeascarehasbeentransformedintoprovisionand
intervention,distributed through thedevelopmentof technologiesofcareand the
machines of calculation. Discretion gets reinvented as negotiation, with a
proliferationof thresholds throughwhichpatientshave topass toaccesscareand
interventions. Asatthesametimeasmoreandmorehealthcare‘work’passesto
patientsandtheirfamilies,peoplearebeingincitedtoperformthemselvesasmoral
in their choices over their style of life and the stuff of life that they choose to
reproduce.
Sothatitseemsthataccountabilityastransparency,hasactedasadividingpractice
to reinforce the rift between care and cure inways that obliterate any hope of a
return to the curecare binary. Rather the care‐cure binary having chiasmic
properties,myfearisthatthereisnoreturn,thatanunbreachablechasmhasbeen
produced.Soquestionsariseastowherecanwegofromhere.
Aretherepossibilitiesforbreachingthechasm–buildingbridgesthatbringthetwo
banksbackintoviewaswhatHeideggerwouldcallalocale–aplaceforthecarecure
binarytodwell?Whatobjectscanbeputintocirculationtoretranslatetheeffects
ofwhatIhavebeendescribingabove? DavinaAlleninherworkonCarePathway
development seems to be suggesting that in the work of their construction care
pathway seem toact asboundaryobjects thatdo someworkof reconfiguring the
kindsofbreachesandchasmsthatIamdescribinghere.
OrwithAnnaMarieMoland IngunnMoser,wecankeep to the local and specific
descriptionsofhowamultiplelogicsofcareisatworkintheorderingofhealthcare
environmentsandmakemorevisiblewhenandhowtheseareoutofbalance:when
choice or efficiency or somatic medicine, for example, becomes too greedy and
dominates, to extrude other possibilities for interpretation and conduct. My
problem here is gracing the administrative nonsense of technologies of care and
calculation,orabiomedicineorientedtothefuture,withanideaoflogic,seemsto
betoogenerous.Mysuspicionisthatthisisaglossofsocialscience,andthatfroma
patient’s,andperhapsevensomepractitioners’,perspectives,thereisverylittlethat
islogicalabouthowcontemporaryhealthcareorganizationisworking.Myquestion
reallypertainsastowhetherwecanbegintothinkofthebreachitselfasaspaceof
possibility?
Figure7
In particular how can we revivemedicine, wrench it back from the future, and
interestitinthehereandnow,howeverdistributeditspractice?Helpitremember
itselfasapartoflife,asneverjustwork,orfunctional,butasworld‐forming?
While not wishing to undermine the suffering and pain sometimes involved, I do
wanttostressthatthefiguringofsickandillbodiesisitselfrelational,aninteraction
betweencertainkindsofbodiesandtheirculturalandsocialworlds.Soforexample,
peoplewithso‐calleddementiafindthemselvesinsocialworldsthattheydonotfit
(Schillmeier 2009), and this lack of fit between how they are, their body and the
worldmeansthattheyfindthemselvesasoutofline(MunroandBelova2009),allof
whichdoesnotjustintensifytheexperienceandthecondition(Schofield2008)but,I
would aver, partly constructs the condition itself (see also Kraeftner and Kröell
2009).Thisrelationalityalsoappliestothehealthissuesofthethirdworld:isaidsa
problemthatinheresinspecificbodiesorarelationbetweenpoverty,culture,global
economicsandthefleshandbloodofindividuals?
Questions arise then as to how we can bring into view methods, narratives and
discoursesthatcirculatedifferenceinwaysthathelpdeconstructtheoldhierarchies:
waysofimaginingthatrevalueboththesickandthefrail,andthecarethatsomeof
usrequire?IamthinkinghereofFlemingandMay’s(1997)paperinwhichtheystress
theimportanceofimagining.
Whiletherehasbeenanemphasisonexploringwaysofthinkingof‘spaces’ofcare,in
ways that privilege attention to issues of self‐determination, dignity, individuality,
privacy and choice, these do not address how care itself is relational and world‐
forming. Thestartingpoint then for reimaginingcouldbe topositadifferent, less
functional notion of care and the involvement of practitioners and patients as
embodied persons in relations (e.g. Rudge 2009, Savage 1995). Here we need to
undoalltheproblematicofthedividingpracticeofwork‐lifebalance:theworkpeople
doisasmuchapartoftheir lifeasanythingelsetheydoormake. MargaretMead
suggeststhattheverynotionofleisureisadominatingtropethatupsetstheideathat
howweworkalsodecidesourlives.
Specifically,wecouldbegintoimagineformsoforganizationembeddedinaviewof
carerouted in ‘body‐worldrelations’ (Latimer2009). Herespacesofcarecanbring
being‐with(mitsein)alongsidebeing‐in‐theworld(dasein),tothinkofspacesofcare
in terms of locale, materiality and relationality, rather than just in terms of
individualisation, face and self, as important as these are. But there are many
possibilitieshere.Let’stalkmoreaboutthem.Thankyou.
i TheMöbiusstripwasnamedafterAugustMöbiusin1885.
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