Intended for healthcare professionals

Editorials

Patients and medical power

BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7310.414 (Published 25 August 2001) Cite this as: BMJ 2001;323:414

Regimes of Truth , Patients & Medical Power

Firstly, it is good to see senior medical personnel engaging with
literature outside biomedicine. This is to be encouraged since medicine is
increasingly defined by people outside its realm and the sooner medical
professiojnals get to grips with the arguments the better will they be
able to fight their corner. Despite Waring's comment about the debate
being somewhat old, I think further explication of Luke's conception of
power would not have been amiss for those without knowledge of the model
to which Canter refers, for, as we shall see, it continues to have
relevance in contemporary culture. Luke's (1987) model can be describes as
having three faces. 1) decision making (Canter's first dimension), which
is self explanatory, 2)non-decision making (Canter's second dimension)
involves using power to prevent issues being discussed or decisions about
them being taken (think government for expert evidence based practice at
this! along with bio medics of course!) and finally, 3) shaping desire by
means of manipulation Canter's third dimension. This latter is a
favourite with advertisers, bio medics amongst others, as well as the
apparatus of the state. From Luke's perspective, those interested in power
are concerned with, the difference that is made, i.e. outcome, and, the
making of that difference, so interest is in the locus of power. The
purposes for which power is being sought will often be thoughtfully and
extensively hidden by carefully constructed discourse.

The above model and Government Rhetoric is steeped in the
Enlightenment tradition which saw the human as possessing some essence of
freedom or liberty which is constrained by social practices (Jean-Jacques
Rousseau - 'Man is born free, but everywhere he is in chains'. By changing
the social practices (abolition of slavery, abolition of monarchist rule
in the French, American and Russian revolutions, emancipation of women and
children, decline of colonialism leading to independent governance,
personal autonomy, shift of power from doctor to patient etc) we liberate
the person from constraints. I will now take Waring's request to widen the
notion of power a stage further.

Foucault's 1979) ideas help us to reverse the above way of thinking.
He did not believe that some utopian situation of 'freedom' can be
achieved, because 'freedom' itself is a product of a discourse that is
historically and culturally determined. Ironically, 'freedom' is achieved
through putting into place 'practices' of freedom, not by removing
constraints. While such practices of freedom offer an illusion of
emancipation, they in fact set up a series of subtle controls to maintain
the idea that autonomy has been achieved. Such practices of freedom, as
practices of 'self' are viewed by Foucault as articulating an ethos that
offers power relationships allowing a minimum of domination.

Now, professional dominance of certain occupational groups is clearly
grounded in the possession of a body of knowledge which is a crucial
feature of the exercise of professional power, (Turner, 1995). Medicine,
like most of the sciences, is knowledge transformed into power. The
theoretical aspects of medicine, constitute the rational experimental
foundations of a science which is then applied by the practitioner. The
doctor - patient relationship is complex, not readily analysed and
influenced by a myriad of cultural factors. I suggest that discourse
surrounding and within this relationship is the most important factor
influencing the character of this relationship because it is here that
other influencing factors are given form or ignored, depending on the
'regime of truth' predominant in a given historical period, Foucault,
1984) (Witness current debate surrounding MMR vaccine to work out how the
latter operates).

Discourse then, is a domain of language use unified by a set of
common assumptions which provide ways of representing a particular kind of
knowledge about a topic, e.g. biomedicine. Here, power rather than facts
about reality make things true. Power and knowledge fit as glove to hand,
always implying one another, discourse being one of the systems through
which power operates. Power, based on control of information (can you hear
Luke's conception in the background here?) may be Administrative or
Disciplinary. Working at the level of the individual and of the
population, through regulatory controls, knowledge of bodies is produced.
The 'known' become 'subject'. Disciplinary power refers to the way bodies
are regulated, trained, maintained, understood. (Most evident in
institutions, hospitals, prisons). Disciplinary power works at two levels;
(1) Anatomo-politics of the human body (individual bodies are trained and
observed), (2)Regulatory controls, a bio-politics of the population
(Concurrently populations are monitored). Knowledge of bodies is thus
produced. There are three main instruments of disciplinary power:

1) Hierarchial observation, i.e. sites where individuals can be observed.
The design facilitates observation.

2) Normalising judgement, attributes/actions of each individual are
compared with attributes/actions of others. This permits a norm to be
established.

3) Examination, combines normalising judgement and hierarchial
observations. Here the individual subject can be assessed and corrected.

The medical encounter according to this perspective or how bodies are
controlled by discourse.

Clinical examination is one of the apparatuses of disciplinary power.
Body is both target and effect of power. Each individual equals a 'case'
(the subject and object of knowledge). Talk of medical dominance is
inappropriate. Patient's self-talk provides opportunity for the medical
gaze to be directed towards them. This therefore, offers subtle,
individualised means of surveillance and social control. Power in this
relation is diffuse, a form of social organisation by which social order
and conformity are maintained by voluntary means. Therefore, power is not
only repressive, but also productive.

Discipline occurs through punishment (lose weight or we won't operate
etc) and gratification via the rewards and privileges for good conduct
(discontinue smoking and you can have the treatment). Both doctor and
patient believe in the importance of medical testing, constant monitoring
and invasive, embarrassing investigative procedures in the interests of
the patient. Explicit coercion is not needed. The patient voluntarily
gives up the body to the medical gaze because that is what people are
socialised to expect.

So, control occurs through (A) Cultural values and norms: Power is
everywhere, enforced as much by the individuals unconscious self-
surveillance as by authority figures. (B)The use of language and
practices: the patient is incited to speak, allowing invisible power
relations to take place within a framework in which the patient is
encouraged to take responsibility for their own behaviour. (Recall the
flurry of policy documents in the 1980s & 90s propounding the role of
disease prevention?). According to Lupton, (1995) 'the dialectic of public
health is that of the freedom of individuals to behave as they wish pitted
against the rights of society to control individual bodies in the name of
health'. She asserts that, 'disciplinary power is maintained through the
mass screening procedure, the health risk appraisal, the fitness test, the
health education programme invoking guilt and anxiety if the advocated
behaviour is not taken up'. In other words, health persuasion techniques,
Beattie, (1993) or indeed, Lukes (1987) third face of power, shaping
desire by means of manipulation, and his second face, that of non-decision
making, because, after all, individuals are unaware that such discourse is
disciplinary because health is portrayed as a universal right and the
source of the discourse as benevolent. 'Power relations are rendered
invisible, and are dispersed, being voluntarily perpetuated by subjects
upon themselves as well as upon others, and thus produced are not simply
the imposed results of alien, coercive forces, the body is internally
lived, experienced and acted upon by the subject and the social
collectivity' (Grosz, 1990:65 cited in Lupton 1995.

In conclusion, Enlightenment humanism (the liberal humanist view)
sees knowledge (education) as a potential to liberate from power, where
power is seen as distorting 'true' knowledge (e.g. Marx's alienation,
Durkheim's anomie, Hegel's development of Spirit, humanism's authentic
self etc). Foucault sees power and knowledge rather as intimately tied.
Knowledge is formulated through power relations. Liberal humanism does
not remove power (Liberation) but merely re-inscribes it, or offers
techniques of 'liberty' and 'autonomy' that are subtle forms of power
relations. Foucault does not perveive 'power' as merely a coercive,
negative, controlling force, but as an integral part of human
relationships, which changes in quantity and quality from one situation
to another and within situations. 'Power' than, is a productive network
which runs through the social body, much more than as a negative instance
whose function is repression. 'Knowledge' (related to what Foucault calls
'trugth-games') is constructed through power relationships. The 'subject'
is a good example of a site of power/knowledge relationships, for the
'subject' is not only agent but also object (one is subject to, or
subjected to) The subject is constituted by a number of social practices
variously in different historical periods. The subject is formulated
through 'games of truth' or validated and invalidated forms of knowledge
and Foucault suggests that subject/truth relations are the central
concern of power/knowledge relations, as humans have constructed various
techniques of the self (care of the self) through history. So we ask,
following Foucault, (a) how are practices and knowledge established
through social discourse, and (b) whart are the particular relationships
between power and knowledge and the subject and truth in any historical
epoch?

References

Foucault, M. (1973) The Birth of the Clinic, London Tavistock.

Foucault, M., (1979 & 1984 "Truth and Power" in (Ed) P. Rabinow, The Foucault Reader, Penguin.

Lukes, S. (1987) Power, Basil Blackwell.

Lupton, D., (1995) Medicine as Culture, Sage, pp 31,32.

Turner, B., (1995) Medical Power and Social Knowledge, 2nd Ed, Sage.

Competing interests: No competing interests

31 August 2001
Mary Curtis
Head of Education & Training Cornish Hospices & Palliative Care Services
Mount Edgcumbe Hospice