Protect the patient from whom? When patients contest governmentality and seek more expert guidance

Original Article

Protect the patient from whom?When patients contest governmentalityand seek more expert guidance

Kathrine Hoffmann Pii and Kaspar Villadsen*

Department of Management, Politics & Philosophy, Copenhagen Business School,Porcelænshaven 18A, DK-2000 Frederiksberg, Denmark.E-mail: [email protected]

*Corresponding author.

Abstract This article presents findings from an empirical study among patients andprofessionals involved in a preventive health program at a Danish hospital. It shows howpatients enrolled in the program interact with health professionals in ways that chal-lenge assumptions common to governmentality studies of prevention and health pro-motion. This literature has successfully explored how contemporary health promotiontransgresses the public/private boundary by shaping the values of collectivities andindividuals to fit better with public health objectives. By exploring the complexco-existence and intertwinements of discipline and biopolitics in preventive practices,this study eschews an interpretation that views the powers of the professional healthsystem as invasive and one-directional. Perhaps surprisingly, the study demonstrateshow patients in various ways defy a ‘patient-centered’ and empowering approach anddemand to be treated medically and disciplined in a more traditional sense. The blurringof the public/private boundary, then, cannot be straightforwardly described as a resultof a professional health system that, more or less subtly, reaches into the private lives ofpatients. A more complex picture emerges, as patients’ attitude reflect both traditionalmedicine and rationalities foreign to the health system.Social Theory & Health (2013) 11, 19–39. doi:10.1057/sth.2012.19;published online 14 November 2012;

Keywords: preventive health; Foucault; ethnography; resistance;

governmentality; atherosclerosis

Introduction

How should we conceive of recent patient-centered health initiatives for the pre-

vention of ‘lifestyle diseases’ and improvement of life quality from a Foucaultian

r 2013 Macmillan Publishers Ltd. 1477-8211 Social Theory & Health Vol. 11, 1, 19–39www.palgrave-journals.com/sth/

perspective? Should they be unveiled as more or less subtle technologies for

social control and optimized productivity, or can they be evaluated as offering

positive, if ambiguous, potentials?

From the perspective of critical health research in a Foucaultian vein, con-

temporary health promotion and preventive technologies have often been in-

terpreted as effecting a critical transgression or blurring of the public/private

boundary, in as far as the private domain is allegedly invaded by public

health concerns. Scholars inspired by Foucault particularly study programs and

‘governmental technologies’ that purport to facilitate the self-responsible

conduct and identity work of patients and groups, hereby supplementing more

conventional treatment based on diagnoses, medicalization and prohibitions

(McGillivray, 2005; Andersen, 2009; Larsen, 2011). These observations have

provoked much critical reflection, particularly among academics and health

professionals. Nevertheless, such analyses of various health promotion strate-

gies often remain on a programmatic, idealized level, excluding the question of

how these strategies are practiced by patients and professionals in detail. Fur-

thermore, the take-up of Foucault still displays a tendency to interpret medicine

and health care as ingrained in more or less subtle strategies for social control

discernible in the ‘first wave’ of Foucaultian health studies (Armstrong, 1983,

1995; Atkinson, 1995; Turner, 1997). These two tendencies make it difficult

on the basis of Foucaultian health studies to identify concrete opportunities

for the agents involved as well as to arrive at a balanced view that includes

considerations of positive benefits of health prevention.

Such difficulties, however, do not imply that we should completely abandon

the governmentality approach or Foucault’s conceptual innovations. In the

below section, we argue that the concepts of biopolitics and discipline may

be mobilized to offer a balanced perspective on health promotion generally, and

preventive practices specifically. The article is divided into four main parts.

First, we discuss some dominant ways of inheriting Foucault within studies of

health promotion and preventive health care. In this section, we highlight some

weaknesses of the generalized Foucaultian perspective on health, especially

with a view to addressing practices of health prevention and practical issues for

the agents involved. Second, we present the concept of biopolitics, which is

contrasted with discipline. Our focus is here how to develop an approach that is

sufficiently complex to grasp the ambiguities of current health promotion

practices that explicitly aim to be sensitive to patients’ values and lifestyles.

A third section concerns methodology with an emphasis on the potentials of

using case studies and on the specific methodological setup in the study that we

draw on. Fourth, we present a case study that unfolds the complex co-existence

and intertwinements of heterogeneous rationalities in preventive counseling

work. It follows that a portrayal of preventive health as invading patients’

HoffmanPii and Villadsen

20 r 2013 Macmillan Publishers Ltd. 1477-8211 Social Theory & Health Vol. 11, 1, 19–39

private lives is too hasty and reductionist in light of the complex contestations

of divergent values observable in day-to-day counseling meetings.

Foucaultian Perspectives on Health Promotion: Some Limitations

It is beyond question that Foucault has had an enormous and growing impact

on the sociology of health in its various dimensions. We will not attempt to

provide a review of this massive and growing literature (for overviews of the

Foucaultian approach to health and medicine, see Petersen and Bunton, 1997;

Patton, 2010). Instead, we undertake the more restricted task of rather briefly

examining how Foucault has been adopted by critical studies of preventive

health care in relation to the question of the public/private boundary.

Although recent Foucaultian studies can hardly be accused of being hemmed

in by the kind of social control paradigm that arguably characterized some early

inheritors of Foucault within the sociology of health (Turner, 1997, p. xi), they

nevertheless share a particular critical emphasis. Thus, they generally take

a great interest in strategies and techniques by which public and professional

health concerns are installed into the private lives of families and individuals.

To be sure, in the view of governmentality studies, these strategies do not

radiate from the state as a unified center of authority. Similarly, it is no

longer the population as an organic whole that is the essential object of health

promotion (Rose, 2001). In ‘advanced liberal’ societies, governmental strategies

are rather exercised through loosely assembled networks of state and non-state

agents (Rose and Miller, 1992). Nevertheless, a key critical point in Foucaultian

health studies is that communities, families or private organizations have

become the object of intrusive and delicate technologies of health promotion.

For the governmentality approach, governmental technologies blur and com-

plicate traditional distinctions between coercion and consent. They presumably do

so by transforming the subjectivities of those who are to give consent or refuse it,

by rendering aspects of themselves and their behavior amenable to observation,

examination, comparisons and judgment. Recent Danish studies of preventive

health care inspired by Foucaultian insights demonstrate that technologies for

shaping self-government and self-identity are often directed not only at patients

but also at partners, relatives and friends, and may target health professionals

themselves (Dahlager, 2005; Andersen, 2009; Larsen, 2011). Others argue that

contemporary medical power seeks to install itself in the internal relations of

individuals and groups, particularly by utilizing patients’ own statements and

values as a means to reach successful treatment (Karlsen and Villadsen, 2008).

The Danish context constitutes an interesting case for our problematic,

as health authorities praise Danish health care for being at the forefront in

Protect the patient from whom?

21r 2013 Macmillan Publishers Ltd. 1477-8211 Social Theory & Health Vol. 11, 1, 19–39

implementing ‘non-tutelary’ and ‘patient-centered’ health initiatives (Kjær and

Reff, 2010). At the same time, Danish health-care specialists and professionals

seem quite receptive to social constructivist and Foucault-inspired critics, which

brings a further urgency for debating the practical functions of this type of

knowledge production.

The observations of the Danish studies broadly resonate with govern-

mentality studies of health promotion across widely different countries and

health domains that offer similar diagnosis of how the private is being per-

meated by public health concerns. To merely give a few examples: Finn and

Sarangi’s study from 2008 demonstrates how the instrument QOL (Quality of

Life), ‘a western-centric’ and ‘neoliberal’ form of health governing, is deployed

by Indian NGOs working with HIV health promotion and prevention. They

critically emphasize how the QOL discourse inculcates a specific way of

knowing health, oneself and life satisfaction, and thereby functions as a global

ideology that overshadows local, cultural understandings and societal struc-

tures (Finn and Sarangi, 2008). Rous and Hunt (2004) discuss a Canadian

prevention project aimed at reducing instances of allergic food reactions among

school children. This study shows how a technology of risk management

became generalized and disseminated with the effect of turning non-allergic

children, school staff and parents into subjects of moral self-regulation aimed

at risk management (Rous and Hunt, 2004). In Ryan, Bissell and Alexander’s

account of women’s breastfeeding narratives, the mothers draw on con-

temporary expert discourse around breastfeeding in their moral discursive

construction of self – a discourse that limits mothers in articulating their

subjective positions (Ryan et al, 2010). Across these very different studies, it is

noteworthy that they all explicitly or implicitly criticize the invasion of official,

modern or Western health values into the private domain; the everyday life of

individuals.

The Foucaultian conceptual apparatus has undeniably led to significant

critical insights. Nevertheless, the way it has been utilized within the sociology

of health reveals certain limitations. First, as mentioned above, Foucaultian

studies typically interrogate programs on their textual surface and examine their

communicative logic, rationality and internal paradoxes. The price that those

studies pay for this privileging of the programmatic level is a neglect of the

complexity of those concrete practices in which preventive health initiatives

unfold. This critique has been voiced both from scholars within the sociology of

health (Lupton, 1997) and within the governmentality tradition itself (O’Malley

et al, 1997). In outline, Foucaultians within health and medicine are criticized

for their neglect of examining how medical programs and categories are taken

up in divergent ways, negotiated, contested or transformed by medical practi-

tioners and lay people. A reoccurring critique from particularly ethnographers



and anthropologists is that Foucaultians offer a deterministic view, ‘in which

discourses are represented as subjugating human agency with little scope for

resistance or acknowledgement of the lived experience of the body’ (Lupton,

1997, p. 101). While we question whether Foucault’s own genealogical work

ever aimed to examine individuals’ lived experiences, the approach arguably

still has an underdeveloped potential for interrogating the diversity and con-

tradictions of health practices (exceptions include Bloor and McIntosh, 1990;

Lupton, 1995; Mol, 2002).

A second type of objection against the governmentality approach to health

promotion concerns the rather negative view of the powers of medicine often

adopted by its proponents. To varying degrees, medicine and health promotion,

including preventive health care, figures as part of regimes of social control.

One striking example is the early work of Armstrong that tends to describe

patients as passive victims caught in the control of a mighty medical regime

(Armstrong, 1983). Admittedly, recent studies of preventive health do not

normally apply such a sinister view. Nevertheless, they generally portray

preventive technologies as highly delicate means to access the private lives of

individuals, shape identities and thereby exercise social control. This rather

negative view on preventive initiatives probably stems partly from the inter-

pretation of the governmentality concept common to studies of health and

medicine. Here, governmentality is typically viewed as a system of power that

connects individuals’ self-regulation with broader strategies for the government

of populations, or as Turner illustratively states: ‘A regime which links self-

subjection with societal regulation’ (1997, p. xv). This one-sided conception

of governmentality should, however, be counterbalanced by attending to Fou-

cault’s more ambiguous use. On the one hand, the kind of political reasoning

that gradually emerged from the seventeenth century has a subtle character as it

both recognizes the freedom of those governed and seeks to shape this freedom

through constellations of discipline, pastoral care and juridical sanctions.

On the other hand, Enlightenment thinking – essential to governmentality –

marked a radically new relationship between subjectivity, truth and power, as it

allowed subjects to question the truth through which they were governed

(Foucault, 1997). In fact, a new sensitivity to the governed and their rationality

is, according to Foucault, essential to modern forms of government. The idea

that government should model itself upon this rationality grants, at least in

principle, the possibility that the governed subjects, for example patients, might

question and resist experts and their institutions.

Third, Foucaultian health studies display a tendency to view health institu-

tions, programs and technologies as productive rather than reactive. With this

we imply that these studies generally demonstrate how the medical regime –

hospitals, health centers, professionals, technologies – constructs subjects,



roles, problems and illnesses, and how this construction is deeply infused

with social powers. On this view, health institutions and preventive health is

‘productive’ in the sense that they produce and intensify a web of relations in

which the government of others and self-subjection intersect (Turner, 1997, p.

xiv). In this respect, the Foucaultian approach appears quite reconcilable with

the earlier medicalization critique that largely portrayed Western medicine as a

hegemonic system that objectify and disempower its patients, while reprodu-

cing the dominant cultural position of doctors and specialists (Atkinson, 1995;

Lupton, 1997). Rarely do these studies consider whether health institutions

and interventions should in some instances be conceived as reactive, that is, as

responses to particular human needs and sufferings.

Foucaultians should take care to eschew a too univocal pathway, we contend,

and become more flexible so as to be able to view health arrangements in

a more balanced perspective. If a key aim of Foucaultian analytical critique is to

open up the space for subjects to question the truth through which they are

governed and undertake alternative self-practices, it must consider the actual

capability of individuals to exercise such practices. It may be argued that this

capability is circumscribed by a range of human functioning and needs, in-

cluding basic health, that constitute conditions for any practice of critique and

self-fashioning (Tobias, 2005). Furthermore, if immanent critique is always

intimately related to the domain it seeks to criticize – implying that it must to

some extent be informed by the voices of this domain – then critique must

recognize, for instance, if individuals valorize preventive health care, as it may

relieve pain, provide cure and bring higher life quality as perceived by patients.

Although Foucaultians have so far been reluctant to take a positive stance upon

preventive health arrangements (and institutional welfare broadly), we suggest

that the approach may be developed with a view to empirical sensitivity and

non-foundational normativity. For this purpose, we briefly draw out some ele-

ments in Foucault’s concept of biopolitics

Biopolitics

Foucault defined biopolitics as the historical moment from the eighteenth

century onwards, where the biological life of man became an object of political

calculation as it ‘passed into knowledge’s field of control and power’s sphere of

intervention’ (Foucault, 1984, p. 142). This political interest implied the es-

tablishment of a range of practices such as public hygiene, health statistics,

surveillance of health standards in different, large city districts, and, much more

recently, the use of preventive programs. We wish to emphasize that biopolitics

is not restricted to targeting people’s biological existence in a narrow sense, as if



only distinct biological and medical problems can appear under the gaze of

biopolitics. Rather, modern biopolitics concerns itself with the biological life

of man as it is lived out within small- or large-scale environments, covering an

almost limitless number of factors that may be perceived as influential upon

living humans.

Biopolitics shares some characteristics with Foucault’s seminal portrayal of

modern discipline (Foucault, 1977), but it does not confine itself to institutions

as the locus for exercising power. It takes ‘man-as-living being’ as its object and

seeks to operate on individuals in all their whereabouts, actions and social

relations, thereby transgressing institutional barriers and dissolving conven-

tional boundaries between the public and the private, the institution and its

outside (Deleuze, 1992; see also Lazzarato, 2002). In brief, and for the purposes

of our analysis below, biopolitics guides our analysis toward programs and

initiatives that do not depend upon the circumscribed spaces of modern

institutions, including hospitals and clinics, but operate on an, in principle,

indefinite number of sites.

Like discipline, biopolitical intervention implies the production of norms, but

such norms do not simply serve to exclude persons or acts, but rather aims to

include (by examining, testing and classifying) as many aspects of human social

existence as possible. This point is made by Nealon: ‘Foucaultian power never

gains a greater hold of the body or a socius than when it intensifies, multiplies

and extends its realms of application (rather than rarifying or calcifying them

within a clumsy, centralized binary scheme)’ (2008, p. 51). Crucially, therefore,

biopolitical interventions are not a matter of judging the usefulness of a person

or human characteristics against a pre-established, rock-hard norm, but rather

of interrogating life forms (even critique and resistance) and intensifying those

elements found to be productive for biopolitical objectives.

This reading of biopower hopefully helps eschew a view of preventive pro-

grams as a means of social control, implying a kind of uniform and unidirec-

tional power originating from the state apparatus. If we give emphasis to the

above understanding of biopolitics as a form of power that seeks to attach itself

to the processes to be governed, recognizing its dependency on the governed,

we achieve the analytical advantage of avoiding a view of public health as

a solid and self-enclosed regime of power. In the analysis below, we shall indeed

analyze preventive health strategies as unstable and ongoing projects, which

are never unequivocal or unidirectional.

Although biopower takes the process, forces, values, or in short ‘the life’, of

the governed as its point of departure, it may nevertheless provoke resistance

and contestation. Such moments of ‘testing’ and contestation are analytically

significant because they may display with particular clarity the logic of

governmental programs. They further allow descriptions of the complex



enactments and concrete (sometimes unintended) effects produced when

programs are enacted, negotiated and challenged by specific agents. Indeed,

Foucault argued that critical analyses of modern expertise may fruitfully take

their starting point where ‘the governed’, in this case the patients, resist their

‘governors’ by questioning the truths through which they are being governed.

Thus, to ‘understand what power relations are about, perhaps we should

investigate the forms of resistance and attempts made to dissociate these

relations’, including ‘the opposition to the power of medicine over the popu-

lation’ (Foucault, 1982, p. 211). Further, Foucault emphasized that practices of

‘counter-conduct’ are always ingrained in the systems of power that people

react against (1984, p. 95). They are never in a position of absolute exteriority in

relation to power but rather utilize the discursive categories and programs

operated by institutions. In this spirit, we focus on the specific struggles in

which patients question the truth claims of health-care professionals, and we

point out some challenges and tensions within preventive practices.

Supplementing Foucault with Ethnography

The following analysis engages in the above discussions by means of findings

from an ethnographic study of a prevention program at two Danish hospitals. It

explores the dynamic interactions of the preventive encounters and the power

struggles of where to settle the boundaries between the patients’ private lives

and public health objectives. A straightforward governmentality analysis of this

case would likely give emphasis to how these preventive health initiatives

construct patients as ‘active partners’ in the quest for health and seek to render

them responsible for securing their own well-being and minimizing their health

risks. Eschewing a ‘governmentality classic’ analysis, we use ethnographic

observations to allow the dynamics and specific power struggles in preventive

counseling to be displayed in greater detail.

Foucault’s work has had quite a resonance within ethnographic studies and

anthropology. It is beyond this article to discuss in detail the strategy of com-

bining Foucault with ethnography (see, for example, Ferguson and Gupta, 2002;

Obrist, 2004; Hill, 2009). We briefly note, however, that the two approaches

are broadly reconcilable in that they both attempt to ‘de-naturalize’ in-

stitutionalized truisms; they work with a ‘decentered subject’ shaped through

social and historical practices; they both bracket the question of true/false (for

example, with respect to disease categories) in order to examine the social

functioning of truth claims. Foucaultians and ethnographers seek to study prac-

tices and their rationalities while seeking to avoid pre-given and reductionist



interpretations, although they certainly use different methods and hold different

intellectual ambitions.

The following analysis comprises data from an ethnographic field study

conducted in 2009–2010 at a vascular outpatient clinic physically located at two

Danish hospitals. Over two periods of 2 months each, one of the authors fol-

lowed the everyday life of the clinic with a special attention to counseling

meetings between nurses and patients.1 The purpose of the study was to explore

how prevention was practiced, that is, how preventive logics and ideals evident

in strategies and programs were ‘acted out’ in the concrete meetings between

health professionals and patients as well as in the local and context-specific

work that links up to these meetings, that is, various practices of administra-

tion, knowledge production, internal planning, and training (a collection of

studies of prevention in practice is offered by Mather and Jansen, 2010).

The study’s data consist primarily of notes taken during the course of fieldwork.

The aim was to achieve detailed registration of the actions that took place

among the health professionals themselves and between the health profes-

sionals and their patients. The notes also include information and quotes from

the numerous informal conversations and interviews undertaken during the

study. These conversations often made reference to previous observations and

thus had as one of their goals to make the health professionals verbalize their

routines and taken-for-granted practices. In addition to these informal con-

versations, the study entailed five formal, semi-structured and taped interviews

with health professionals (including the managing doctor and the chief nurse),

furthermore a focus group discussion with seven nurses was conducted, three

patient interviews made in the patients’ homes and three prevention con-

sultations were videotaped. The following case description uses unspecified

names and has redacted some identifying details in order to secure the parti-

cipants’ anonymity. All involved health professionals have been informed about

our study and acceptance was obtained from all participants that they might be

observed during work. Patients and patients’ relatives were also informed about

the study and gave their permission to be observed during prevention meetings.

On numerous occasions, actions and conversations were observed that pose

a challenge to the conclusions drawn in other Foucault-inspired prevention

studies. In particular, our findings challenge the general critical tenor in this

literature that displays the subtle installment of public health concerns in pri-

vate domains. As we shall see below, patients sometimes used the expressions

and models offered by the health professionals as a means to speak about and

understand their condition and the preventive efforts. Nevertheless, the same

patients challenged key assumptions of the program as far as they often inter-

preted the prevention strategy in their own terms and made unexpected

demands of the program. In this article we foreground these cases, not because



they are representative in a strict quantitative manner, but because they allow

us to supplement and challenge received critiques in governmentality studies.

They thus become, following Flyvbjerg’s definition, ‘critical cases’ that might

have a generalizable, critical quality as they permit the question: ‘if this is valid

for this case, it is valid for all (or many) cases?’ (Flyvbjerg, 2006, p. 230).

Furthermore, as prevention of lifestyle diseases is adopted by an increas-

ing number of hospitals and health institutions in Denmark and abroad, the

complexities that this case displays are likely to be found in other contexts.

However, we leave it to the reader to ascertain the particular resonance the case

may have in other national contexts.

The first part of the analysis describes the program setup and examines how it

is reflected upon by health professionals at an idealized or ‘programmatic level’.

The second part focuses on how the program unfolds in practice by describing

in detail a series of preventive encounters between health professionals and

patients.

The Prevention Program

The prevention program is based on a vascular out-patient clinic, which is

located at two public hospitals in Denmark. It targets atherosclerosis, a vascular

disease that may lead to fatal strokes and heart attacks. Atherosclerosis is a

condition caused by fat building up on the inside of the arteries, which reduces

the passage for blood flow. The condition does not always have fatal con-

sequences but may entail serious symptoms such as painful leg cramps and

wounds that cannot heal due to insufficient blood flow. Atherosclerosis is a

chronic disease and treatment therefore aims at relieving symptoms by different

surgical procedures (for example, balloon/stent and bypass operations) and

preventing a worsening of the condition. The preventive treatment, which is our

interest here, consists of prophylactic medication (anticoagulant and choles-

terol-lowering medicine) and nurse-conducted conversations, which focus on

the so-called ‘lifestyle factors’ that significantly affect the condition. The con-

versations have an informative scope, as stated in the information material

provided for patients. ‘You will be offered to be educated in how smoking,

exercise and eating habits influence the development of atherosclerosis. You

will be offered smoking cessation support, healthy diet advice and preventive

medical treatment. The sessions are individual and based on what you are able

to do by yourself and what you are motivated to do’ (Patient Information 2008,

Vascular Clinic, Hospital X).

The program places emphasis on the individual patient and his/her particular

conditions and personal motivation for lifestyle changes. In an interview with



the managing nurse, who was one of the initiators of the program, she said that

the pedagogical question of how to inform patients was an issue that greatly

occupied the nurses in the development of the program. The nurses who were

in charge of establishing the methodological setup of the program found

‘Motivational Interviewing’ especially inspiring and decided to build on this

approach. In the interview, the managing nurse explained:

Because it is about starting with the patients and getting them to tell us

what the problem is; and at the same time give them some actual

guidance and information and help them decide how to go about it all.

So, already at that time, we were discussing power structures: How far can

we intervene? What is my role? What can I tell them [to do] So we ended

up with what we do now, that is, trying to motivate the patient and their

relatives who might do the cooking, who might also be smoking, call

them in and talk with them, and try to motivate them.

The motivational approach, which is well established within the Danish

health-care system, draws upon psychological theory about behavioral change

(Prochaska et al, 1994). It claims that in order for individuals to make beha-

vioral changes, they must be motivated at a personal level. Scientific facts and

information do not directly lead to behavioral changes. Individuals’ self-stated

concerns, motivations and goals are therefore key components in behavior-

changing processes. As one of the nurses explained, ‘We don’t tell people what

to do. We try to find out what motivates them and what is possible for them in

their particular life situation and then we support them in their decisions and in

the process’ (field notes). The nurses contrasted this approach to former times’

allegedly moralizing and disciplining attitudes, which they often referred to as

‘finger wagging’ and ‘ear-pulling’.

The program’s attention to patients’ experience and values and its cautions

against excessive regulation echoes some of the characteristics of biopolitics

described above. The attempt to effectuate health ambitions through the

involved patient’s own evaluation of their condition and self-stated motivation

to change behavior was clearly evident in the prevention conversations between

nurses and patients. Here, nurses connected prevention to patients’ hobbies,

interests, aspirations for the future, family situation, work life and so on.

‘If you are going on that trip next year, then perhaps this could be a motivation

to quit the cigarettes and get out and walk, so you can increase your walking

distance and actually be able to follow the group tours?’ Spouses were invited to

participate in the conversations as it is acknowledged that individuals’ behavior

is socially comprised. The nurses gave detailed prevention tips that relate to

the patients’ particular likes, habits and living situation, ‘If you know, that

watching the television makes you smoke, perhaps you could prepare yourself



for this – make some healthy snacks that you can chew on – sometimes

it’s more about putting something into your mouth than the actual nicotine

abstinence’ or ‘You say you have a balcony, have you considered having fresh

herbs? They could substitute the mayonnaise in your sandwich’. They also

suggested small steps toward lifestyle changes, so that patients were not put off

by too ambitious aims,‘You don’t have to quit eating cheese completely, but say,

save it for weekends or skip every second day. That will reduce a lot of fat in

your diet’ (Quotes from field notes taken during prevention conversations).

Although the prevention program did not explicitly require that nurses

appeared as role models, a commonplace ideal in health counseling, the nurses

nevertheless reflected on this issue. During the conversations patients might

rewind the personal gaze back upon the nurse and ask them about their

personal experiences with smoking cessation, eating habits and exercise

routines. During a conversation, one of the nurses was asked whether she had

butter in her fridge or not, a question she was reluctant to answer. After the

conversation she explained that she drew a line between the professional, the

personal and the private – it was alright to be personal, but there were no

requirements for her to expose private matters such as the content of her fridge.

Although the program did not entail any expectation upon the nurses’ ethical

self-relation or require them to act as role models, the quest for intimacy in

counseling sessions might require that they brought in ‘the private’.

Several of the observations made by the governmentality studies discussed in

the first section resonate with the rationality of this program. First of all, the

program expressed a respect for the autonomous individual, patients’ freedom

of choice, and the personal conditions and motivations of each patient.

Furthermore, the program was not only aimed at the individual patient but

included the patient’s wider environment – family situation, social network,

occupation, leisure time, living conditions as important issues in counseling

sessions. Second, the health professionals’ statements and practices expressed a

critical self-examining reflection about their approach to the patients. They

entailed an ambition to break from the authoritarian ‘expert-approach’.

Although the health tenets of the program rested upon biomedical knowledge, it

recognized that scientifically tested data are not the only kind of knowledge that

patients live by and for this reason the program attempted to link biomedical

knowledge to practices, actions and beliefs foreign to biomedicine.

In the following we explore the dynamics of the prevention conversa-

tions and, in particular, how compliance and non-compliance or conduct and

counter-conduct intertwined. We demonstrate that patients opposed and chal-

lenged the program at the same time as they faithfully continued to attend

the consultations. We also observe that patients at times would engage in the

program with motives completely foreign to the program’s scope.



Prevention Interactions

This section gives emphasis to exploring the unstable, fluctuating and reversible

character of preventive counseling practices. A key objective of the prevention

program was to make patients aware of and reflective about their lifestyle and

how it influences their condition. A clear emphasis was placed on the individual

patient and his/her self-stated motivation, capability and choice to translate

these reflections into practice, that is, to undertake concrete lifestyle changes.

The key locus for prevention was thus situated ‘inside’ the patient, as moti-

vation was defined as an internal rather than an external matter. In what fol-

lows, however, we give examples of a number of patient approaches, which

opposed this objective and brought in very different motivations and rational-

ities to the preventive encounters. The notion of discipline as a strategy that

objectifies the persons to be worked upon by means of expert knowledge may

be invoked in this context to describe the conventional medical approach that

operates through diagnoses, predictions and prescriptions. We term this strat-

egy as one of ‘externalization’. In contrast, the biopolitical strategy may be

described as one of being sensitive to the opinions, values and processes

inherent to the people targeted by preventive work. We use the term ‘inter-

nalization’ to indicate this other, and partly contrasting, dimension of pre-

ventive practices.

Internal versus external motivation

During a prevention conversation one of the nurses, Lisa, asked her patient,

Esther, a woman in her 80s, how her smoking cessation was going. Esther

reported calmly and factually how she in the last couple of months had been on

and off cigarettes. As to defend these ups and downs, she exclaimed: ‘But I

talked to one of my friends at the gym, and she said, “just continue to try

stopping, even if you fall off the wagon, just continue”, so that is what I am

doing!’ Lisa confirmed smilingly and commented that it was really good that

Esther was motivated, and yes she should just continue as her friend told her.

Esther accepted: ‘Yes, I know. I know I must stop!’ But at this point Lisa cor-

rected her, ‘It is actually much better if you say “I want to stop”. If you say

this “I must”, then it becomes something outside of you’. She illustrated with

her hands on the table: clenching one hand while curving the other hand

around it in a half circle. ‘You see?’ Then she placed her hand on her chest

and said, ‘It is much better if it comes from within, and when you say “I want to

quit smoking” ’. This boundary between internal and external motivation was

invoked in many conversations, and nurses stressed that it was important

that patients’ made their own evaluation of what they wanted and what was

possible for them instead of trying to satisfy external expectations. However,



this ‘internalization’ principle was challenged on several occasions. The fol-

lowing examples show how patients sought to externalize prevention by calling

for more involvement by the health professionals and their professional ex-

pertise as support for the patients’ own preventive work.

Guilt as motivation

At the end of a prevention conversation, the nurse, Sara, asked Christian, a male

patient in his 50s, ‘So, what do you think? Is there something else I can do for

you? Is there something you think I could help you with?’ In a previous con-

sultation, his blood pressure had been alarmingly high. This corresponded with

his explanation that he had not renewed his prescription for blood pressure-

lowering medicine. Sara expressed her concern about this and explained the

importance of taking medicine when suffering both from hypertension and

atherosclerosis. She told him that she would like to see him in a month in order

to check up on his blood pressure. Before the conversation, she had stated that

he was one of the more challenging patients. He did not seem very keen to

consider quitting his cheroots or doing more exercise. ‘But that’s fine’, she said,

‘then we can work on something else, at least make sure he takes his medicine’.

Yet, even this had been difficult. ‘He even asked me if he could skip it in the

weekends! But you see here in the journal, I have written that he didn’t really

understand his diagnosis and why he had to take the medicine, so we just have

to continue explaining and repeat it again and again’. Christian’s blood pressure

was measured during the session and had dropped. ‘I have been taking my

medicine every day!’ he proclaimed proudly. During the conversation, they also

talked about how exercise and reducing his smoking could improve his con-

dition, but Christian did not give a convincing impression that he was moti-

vated to this. At the end of the consultation, Sara asked him what else she could

do for him. He shrugged his shoulders, when she asked him if he wanted to

come again or if they should end treatment. ‘No, I would like to come again’, he

proclaimed and continued, ‘then I have something that gives me a guilty con-

science!’ Sara furrowed her brow and replied, ‘But you shouldn’t feel guilty – it

is totally up to you what you want to do with all these things, I am just here to

push you in a positive way – I don’t want you to feel bad’. Christian shrugged

again and suggested ‘No, but perhaps that is what is needed’ (field notes).

Christian’s actions and statements display an ambiguous engagement in the

program. He would show up for the conversations but at the same time he

seemed reluctant toward the purpose of the program. Furthermore, he ex-

pressed that his motivation is of the direct opposite kind of what the program

values. He suggested that external obligations and the experience of guilt vis-

a-vis the nurse have a motivating impact on him. Christian was not the only

patient who expressed that he felt that a binding relationship to the nurse had



responsibilizing and motivating effects. Although the program focuses on pa-

tients’ self-relation, patients may still construe the program’s goals differently

and pursue this interpretation.

The quest for expert guidance and intervention

For other patients, the personal relationship with the health professional was

not the key motivational factor in their preventive work. John, a male patient in

his 60s, requested more expertise and clear-cut knowledge in relation to his

prevention activities. In an interview conducted at his home, he said, ‘There are

good intentions in the program, but I need action behind the words. And then

you can say – well, that’s up to you. Yes, that’s true. But if the program is

supposed to be sensible, then there must be an action plan that ensures that

the program is reasonable and that it has an effect – I miss that action plan’.

He particularly asked for ‘professional expert guidance’ about how to use

fitness equipment in the most effective way. John expressed that he knew that it

was for him to take action as he was well aware of the tenets of healthy diet and

exercise. John and his wife had changed their diet dramatically in accordance

with recommendations in one of the folders he had received from the clinic and

had found it very helpful: ‘(y) That’s a concrete action plan, one can say –

good illustrations, examples, recipes – especially a table where you can see

what’s good and what isn’t’. But he lacked similar instructions in relation to

exercise. He exercised several times per week – walking, swimming, bicycling

and fitness – but he requested guidance on fitness exercises: ‘There are so many

things you can do, certain exercises and these must be specified by a profes-

sional, so that you don’t do something wrong’. John had therefore, on his own

initiative, asked for professional guidance at his local gym. This had been very

successful and he suggested that the program should include physical training

sessions with professional instructors.

Esther, who was presented above, had similar expectations from the program.

These expectations did not, however, revolve round expert instructions but

expert interventions. In an interview at her home she explained that she

thought it was a clever idea to attend the program in order to get a bypass

operation in her leg. She reasoned that if she attended all the sessions and

showed engagement and willingness to quit smoking, this would improve

chances of getting an operation, but she did not explicate this to her nurse.

However, Esther’s display of willingness to change did not have the outcome

she expected. In fact, her continuation in the prevention program postponed

the operation. For as long as the patient was able to live with the condition

and engage in prevention by trying to quit smoking, by walking, eating healthy

and taking the medicine, the operation was put on hold to evaluate how these

practices affected the condition.



John and Esther both demonstrated that they understood well the inter-

nalizing principle of the program, and thus, in this case, professional health

aspirations hardly inscribe themselves subtlety into subjectivities. Rather,

they both challenged these aspirations by expressing expectations for more

expert involvement in their prevention work. However, these expectations

were not met.

The possibility for socializing

Another issue that appeared in an interview with one of the patients was that

patients sometimes had reasons and strategies to engage in the program that

were absolutely foreign to the program’s key purposes. Kaj, a male patient in his

late 50s, said frankly that he saw the conversations as ‘entertainment’. Kaj did

not only have atherosclerosis, but had several diagnoses, including Leukemia,

that had put him on disability pension 15 years ago at the age of 45. He was also

recently diagnosed with diabetes, and on top of this, he suffered from depres-

sion. He attended numerous meetings and consultations owing to his illnesses

and he explained that the conversations at the clinics essentially gave him a

purpose to get out of bed in the morning. He was especially fond of his nurse

Louise, the nurse at the vascular clinic because they had a good chemistry and

she even knew something about his great passion for antiquities (Field notes;

visit at Kaj’s home).

During Kaj’s third conversation with Louise, she expressed doubt that she

could do much more for him. Kaj had stopped smoking and he had made some

diet changes owing to his diabetes that mainly consisted in reducing his con-

sumption of sugar. But a still remaining problem was reducing fat in the diet

along with the issue of daily exercise. Kaj proclaimed that he was simply ‘a lazy

bugger’. ‘I get up in the morning after a whole night’s sleep – I sleep like a baby –

I have my breakfast and medicine and then I almost dose off while having my

coffee, I get so tired’. He also explained that walking was too painful for him and

that after 200 m he would scream from pain. The diet recommendations also

proved difficult, although his wife attended the conversations with him and had

tried to change their diet. Louise listened to what they said and suggested that

perhaps he should just be content with what he had actually achieved. ‘I don’t

think you are lazy Kaj, you have achieved so much, you should feel proud about

it, it’s not easy to quit smoking and maybe we can’t do more for you’.

Kaj nodded, but then said that he really liked coming and that he felt privileged

that he could come and talk and that it all helped him thinking about what to

do. He insisted on coming again and Louise agreed to see him again in

6 months. As they said goodbye, Kaj held on to her hand for a while, reminding

her about the coming antiquity festival in his home town. For Kaj, the clinical

encounters with Louise and other health professionals had an extended



meaning. It was not only about the information they could offer or medical

control, it was to a great extent an occasion to get out and socialize with other

people and speak to a dedicated listener.

While these forms of action did not exactly overturn the prevention pro-

grams’ aims or rationale of internalization, they certainly demonstrate that

neither the program’s tenets nor methods were silently accepted by or subtly

internalized in patients. The encounters between nurse and patient were indeed

characterized by a dynamic of consent and contestation. Our interrogation of

these forms of alternative patient strategies for engaging in the program thus

offers a supplement or a counterbalance to claims that public health objectives,

more or less subtly, invade the private. Paying attention to how the prevention

program unfolds in practice, a more nuanced picture of the interaction begins to

emerge in which ‘the private’ on occasions might ‘invade the public’. In this

process, demands for a more all-encompassing form of intervention and in-

volvement were directed at health professionals.

Conclusion

Our observations take up an interlocutory relationship with the govern-

mentality approach to preventive health in a number of ways. First, we agree

with governmentality writers that the conventional oppositions of public/pri-

vate, lay/professional, coercion/consent, internal/external motivation are of

little use for describing the complexities in current preventive health practices.

Preventive technologies – and their unfolding in practice – indeed operate

across and often seek to actively dissolve these binaries. Second, paralleling

governmentality studies, we observed that contemporary preventive health

seeks to shape patients’ identities and their social surroundings in non-

authoritarian ways that reflect well what Foucaultians term ‘government’.

Our study sought to explore and display how these transgressive and reversible

governmental logics were acted out in the daily practices of preventive coun-

seling encounters.

The article began by discussing and evaluating the critical attitude toward

health and preventive strategies shared by most governmentality studies. On

this backdrop, we argued for undertaking a Foucault-inspired approach, which

was slightly dislocated in light of the objections against a too one-sided fram-

ing of modern health promotion. The resulting observations supplement the

governmentality approach, which risks painting a too rigid picture of a private

domain that is supposedly invaded by authorized, public health concerns.

Going beyond the programmatic level evident in textual material, the analysis

explored how patients engaged in a prevention program with greatly divergent



reasons, strategies and expectations. Thus, particular attention was given to

how interactions between patients and health professionals would unfold in

highly divergent ways within the same program setup.

We thus attempted to avoid an a priori negative evaluation of preventive

initiatives and health promotion. Positively, we observed how the governmental

practices, that is preventive counseling sessions, on several points allowed

patients to contest the truths through which they are being governed. The

patients utilized this possibility to various degrees, and some even brought

‘preventive-foreign’ rationalities into the counseling sessions. We suggest that

the program’s emphasis on the personal life and the values of patients produces

a complexity that bounces back to the program in terms of a multiplicity of

heterogeneous demands rooted in the private domain of patients and their

relatives. We observed, for instance, how individuals’ private needs for a con-

versation partner strained the system. A conclusion following from this is that

the greater complexity of contemporary, non-tutelary prevention work

necessitates new decisions to be made as to which statements are preventive-

relevant and which can be left aside.

Noteworthy is also that several patients sought traditional medical objectifi-

cation of their illnesses – that is, clear-cut diagnoses, intervention and expert

guidance on lifestyle matters, including how to eat and exercise most effec-

tively. In this way, what we termed the program’s biopolitical ‘internalization

strategy’ and its quest for self-responsibility was contested. To be sure, clear-cut

diagnoses and technical numbers offer a way of resolving ethical questions or at

least of relocating them into a technical and seemingly rational and neutral

register. The overloading of problems, concerns and needs from the private

lives of patients upon health professionals counteracts, however, such attempts

to discipline and objectify people with lifestyle illnesses. Therefore, the struggle

between the health system and the patients may to a great extent be seen as a

struggle about who is to bear the complexity of fundamentally ethical and

political questions.

Our observations have practical as well as theoretical implications. Patients’

resistance toward what we term the ‘biopolitical internalizing rationale’ poses a

challenge to health professionals who are apparently engaged in a struggle to

break with earlier forms of tutelary and disciplinary health care. Furthermore,

our study challenges governmentality writers who have focused their analytical

critique on displaying the subtle incursions of health values into the private

lives of individuals and collectivities. We started out by asking, protect the

patient from whom? The possible answers are manifold and cannot be easily

settled: Paternalistic, authoritarian health professionals? Empowering, ther-

apeutic professionals? The patients themselves? Or, well-meaning, but distant,

academics?



Acknowledgements

We wish to warmly thank the two anonymous readers for Social Theory

and Health for their fruitful comments and constructive criticism. We also

wish to express our gratitude to the managers and staff at the Department of

Vascular Surgery at Rigshospitalet, Denmark, for granting us access and letting

us observe their preventive work, and to the patients who agreed to participate

in the study.

About the Author

Kathrine Hoffmann Pii is a PhD student at Copenhagen Business School at theDepartment of Management, Politics and Philosophy. She has a Master inAnthropology and uses ethnographic methods in her work. In her PhDproject, she studies prevention practices among health professionals andpatients and deals with the different kinds of responsibility that preventionwork entails for the clinical organization, the health profession and theindividual.

Kaspar Villadsen is an Associate Professor of Sociology at Copenhagen Business

School. He has published extensively on issues of welfare, social policy, and

Michel Foucault, including in Journal of Civil Society, Public Management Re-

view, Constellations, and Culture and Organization. He is the Author, with

Nanna Mik-Meyer, of Power and Welfare: Citizens’ Encounters with State

Welfare, which will be published by Routledge in late 2012.

Note

1 The article is a product of a collaborative work, but Kaspar Villadsen is mainly responsible forthe theoretical part, whereas Kathrine Hoffman Pii is responsible for the fieldwork presented.

References

Andersen, N.A. (2009) Power at Play: The Relationships between Play, Work and Governance.

Houndmills, UK: Macmillan.

Armstrong, D. (1983) Political Anatomy of the Body: Medical Knowledge in Britain in the Twentieth

Century. Cambridge: Cambridge University Press.

Armstrong, D. (1995) The rise of surveillance medicine. Sociology of Health & Illness 17(3): 393–404.

Atkinson, P. (1995) Medical Talk and Medical Work. London: Sage.



Bloor, M. and McIntosh, J. (1990) Surveillance and concealment: A comparison of techniques of

client resistance in therapeutic communities and health visiting. In: S. Cunningham-Burley and

N. McKeganey (eds.) Readings in Medical Sociology. London: Routledge.

Dahlager, L. (2005) I Samtalens rum: En magtanalyse med afsæt i den livsstilsrelaterede

forebyggelsessamtale. PhD-afhandling, København: Københavns Universitet.

Deleuze, G. (1992) Postscript on the societies of control. October 59(Winter): 3–7.

Ferguson, J. and Gupta, A. (2002) Spatializing states: Toward an ethnography of neoliberal

governmentality. American Ethnologist 29(4): 981–1002.

Finn, M. and Sarangi, S. (2008) Quality of life as mode of governance: NGO talk of HIV ‘positive’

health in India. Social Science & Medicine 66(7): 1568–1578.

Flyvbjerg, B. (2006) Five misunderstandings about case-study research. Qualitative Inquiry 12(2):

219–245.

Foucault, M. (1977) Discipline and Punish: The Birth of the Prison. New York: Vintage Books.

Foucault, M. (1982) The subject and power. Critical Inquiry 8(4): 777–795.

Foucault, M. (1984) The History of Sexuality: Vol. 1. New York: Vintage.

Foucault, M. (1997/1999) What is critique? In: S. Lotringer (ed.) The Politics of Truth. New York:

Semiotext(e).

Hill, M. (2009) Ways of seeing: Using ethnography and Foucault’s ‘toolkit’ to view assessment

practices differently. Qualitative Research 9(3): 309–330.

Karlsen, M.P. and Villadsen, K. (2008) Who should do the talking? The proliferation of dialogue as

governmental technology. Culture & Organization 14(4): 345–363.

Kjær, P. and Reff, A. (2010) Ledelse gennem patienten – nye styringsformer i sundhedsvæsenet.

København: Handelshøjskolens Forlag.

Larsen, L.T. (2011) The birth of lifestyle politics: The biopolitical management of lifestyle diseases

in the United States and Denmark. In: U. Brockling, S. Krasmann and T. Lemke (eds.)

Governmentality: Current Issues and Future Challenges. London: Routledge.

Lazzarato, M. (2002) From biopower to biopolitics. Pli: The Warwick Journal of Philosophy, Themed

issue Foucault: Madness/Sexuality/Biopolitics 13: 112–125.

Lupton, D. (1995) The Imperative of Health, Public Health and the Regulated Body.

London: Sage.

Lupton, D. (1997) Foucault and the medicalisation critique. In: A. Petersen and R. Bunton (eds.)

Foucault, Health and Medicine. New York: Routledge.

Mathar, T. and Jansen, Y. (eds.) (2010) Health Promotion and Prevention Programmes in Practice.

How Patients’ Health Practices are Rationalised, Reconceptualised and Reorganised. Bielefeld:

Transcript.

McGillivray, D. (2005) Fitter, happier, more productive: Governing working bodies through wellness.

Culture and Organization 11(2): 125–138.

Mol, A. (2002) The Body Multiple: Ontology in Medical Practice. Durham, NC: Duke University Press.

Nealon, J.F. (2008) Foucault beyond Foucault: Power and Its Intensification since 1984. Stanford:

Stanford University Press.

Obrist, B. (2004) Medicalization and morality in a weak state: Health, hygiene and water in Dar es

Salaam, Tanzania. Anthropology & Medicine 11(1): 43–57.

O’Malley, P., Weir, L. and Shearing, C. (1997) Governmentality, politics, criticism. Economy and

Society 20(4): 501–517.

Patton, C. (2010) Rebirth of the Clinic, Places and Agents in Contemporary Health Care. University of

Minnesota, Minneapolis, MN: University of Minnesota Press.

Petersen, A. and Bunton, R. (eds.) (1997) Foucault, Health and Medicine. New York:

Routledge.

Prochaska, J.O., Norcross, J.C. and DiClemente, C.C. (1994) Changing for Good. New York: Avon Books.

Rose, N. (2001) The politics of life itself. Theory Culture & Society 18(6): 1–30.



Rose, N. and Miller, P. (1992) Political power beyond the state: Problematics of government. British

Journal of Sociology 43(2): 173–205.

Rous, T. and Hunt, A. (2004) Governing peanuts: The regulation of the social bodies of children and

the risk of food allergies. Social Science & Medicine 58(4): 825–836.

Ryan, K., Bissell, P. and Alexander, J. (2010) Moral work in women’s narratives of breastfeeding.

Social Science & Medicine 70(6): 951–958.

Tobias, S. (2005) Foucault on freedom and capabilities. Theory, Culture & Society 22(4): 65–85.

Turner, B.S. (1997) Foreword: From governmentality to risk, some reflections on Foucault’s

contribution to medical sociology. In: A. Petersen and R. Bunton (eds.) Foucault, Health and

Medicine. New York: Routledge.



Protect the patient from whom? When patients contest governmentality and seek more expert guidance

Documents

Transcript of Protect the patient from whom? When patients contest governmentality and seek more expert guidance