Consumer Medicine: what sort of power do we have?

In The Subject and Power, Michael Foucault lays out a framework for understanding relationships between how we are placed as subjects, power, institutionalized power, and struggles surrounding these issues [1]. In trying to understand these subjects, he looks at struggles against forms of power in his time that he felt illustrated these issues, for example: "...opposition to the power of men over women, of parents over children, of psychiatry over the mentally ill, of medicine over the population, of administration over the ways people live". Medicine is an important example of power for two reasons. First, people overlook the ways in which medicine represents power held over others, particularly the popular classes. Second, our relationship with medicine has undergone some drastic revisions which both make understanding its power crucial and challenging.

Speaking about these struggles, Foucault notes,

"They are an opposition to the effects of power which are linked with knowledge, competence, and qualification: struggles against the privileges of knowledge. But they are also an opposition against secrecy, deformation, and mystifying representations imposed on people. There is nothing "scientistic" in this (that is, a dogmatic belief in the value of scientific knowledge), but neither is it a skeptical or relativistic refusal of all verified truth. What is questioned is the way in which knowledge circulates and functions, its relations to power. In short, the regime du savor".

Whether or not we agree with the analysis, something important is discussed here. The power of medicine are connected to a few things: institutional privileges mediated by the state (qualifications), an ideological framework of knowledge which is the property of professionals, and that struggles against medicine focus on the relationships between the institutions, the privileges/powers of the professionals, and the subject. He recognizes components of these struggles as "...struggle against the forms of subjection-against the submission of subjectivity...". That is, people struggling against the way in which Medicine makes them subjects.

Stepping back, medicine through its clinics, educational arms, hospitals, popular science, and media creates subjects through its relationships with people and it's practices. The role grows up within capitalism, and is mediated and empowered by its position in relation to the State and capitalist business (which both constitutes and invests in its functions). Medical institutions are institutions of ideology and power, in a parallel manner to schools, prisons, the military, etc. They are important sites wherein ideology is reproduced.

This is obscured by the fact that in medicine, the ideology is not obvious as could be argued in say prisons or schools. Ideology instead is made up by the relationship of patients and family to physicians, the bureaucracy, other patients, etc. Patients at each step experience medicine through the prism of class, race, sex, sexuality, etc., relationships and the existing hierarchies therein. It teaches you to know your place, much in the way that schools are structured around and educational in learning one's position in society. Healthcare is a vehicle to reproduce submission of one's control over your body to professionals and institutions, whether literally in some cases or more often than not symbolically.

This is not to say that DIY-medicine is automatically liberating or a good way to go. Rather, everything we do in society is reflective of the dominant power relations created and reproduced through the relationships that make up capitalism and state hierarchy. There is not an "outside" where we could create a free medicine liberated from the bounds of power. Instead struggles around liberating healthcare need to occur around the constitutive power relationships that produce an industry of submission and subjugation.

However, the role of medicine that Foucault writes about here, and 20 years early in the Birth of the Clinic, does not exist. Today we find ourselves in a strange place where the prior obvious or naked power of the physician has been unalterably changed. With every day, patients have more and more power in a sense. As healthcare becomes increasingly consumer driven, advertisement laden, and funding tied to consumptive concepts, these roles are shifting. Yet the power healthcare consumers receive is not a power that liberates them from the poverty of healthcare resource availability, the domination by authorities over their bodies, or other such subjugation. Instead it becomes one of apparent choice and apparent freedom, which is increasingly determined by the market and indeed is leading to reduced standards of care.

Through the healthcare reform act, funding is now being tied to customer surveys by patients. Soon funding will be determined in part due to "outcomes" (hospital readmissions, overall health, etc). Such structural reforms by the state have already induced hospital management to revise how healthcare workers spend their time, towards giving patients the feeling of being well served. Hourly rounds aimed at giving patients the sense of people having enough time (while horribly understaffed) and being served like a hotel (at the expense literally of doing proper medical work to improve people's health) are leading to large time shifts towards the manipulation of patient perception. This is a different form of subjectivity. When our relationship to our bodies and our families, increasingly is subjected to market psychology and competition, it is likely that people will find themselves more dependent upon a system that profits from their misery.

1. Foucault, Michael. The Subject and Power. Critical Inquiry, Vol. 8, No. 4 (Summer, 1982), pp. 777-795