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Biomedicine and technocratic power.

Current developments in biomedicine promise a genetically engineered and better future.(1) A "genetic future" would mean incorporating more high technology medicine into the habits of everyday life. The order of the body, that is, the sense of how we should look, act, and perform, would become the domain of conventional medicine, and we would look to medicine to intervene in human performance, ability, and even character when we thought these were less than they should be. Our willingness to accept medicine in this capacity would require the deeper conviction that technological developments and scientific discoveries are proper measures of human progress.(2)

Such attitudes are not remote from contemporary values. We live in an era in which many personal and social problems are treated as if they were matters capable of technical solution-the interventionist response to infertility through in vitro fertilization is an example. Such a belief system conceals from us the probability that advanced technology will not successfully solve the complex social problems we think it should. Moreover it grants to advanced technology, and those who own and control it, a high social value. Indeed, so highly valued is technical knowledge that it can supersede moral considerations and argument in providing a base upon which therapeutic and research decisions are taken. For example, the widespread use of amniocentesis and chorionic villus sampling, which foretell the sex, health, parentage, and future diseases of the fetus, has the immediate appeal of decreasing the numbers of damaged and defective newborns by indicating the "need" to terminate a pregnancy but, simultaneously, the same technology has the latent function of determining which human lives are more valuable, or in utilitarian terms, which individuals are potential welfare burdens to the community in the long term.

Measuring the future capacities of a fetus is a form of human accounting that estimates the individual's future costs or contribution to the society. As early diagnostic and screening procedures become technically commonplace, a classification of human traits deemed suitable for remediation is simultaneously coming into effect. In the future, as more of our genetic abilities and characteristics are foretold by technically sophisticated probes, we would look to medicine to intervene to ensure that our physical appearance and capacities are in accord with current standards of normalcy.(3) In these circumstances, the practices of biomedicine have the latent function of social engineering.

Michel Foucault has argued that this is characteristic of medicine in the West, whose development is coterminus with an account of how social power is accumulated by an elite profession through its increasingly esoteric technical base.(4) The rapid increase in the medicalization of various human conditions has served to promulgate the view that medicine can perfect human life. Many of the current well publicized developments in medicine such as genetic testing, transgenic engineering, organ transplants, and so on, promise a perfected human in a future bio-utopia where debilitating diseases and degeneration have been effectively eliminated.(5) In such a future, our dependence on medicine to specify and regulate how we should live and behave has the effect of indenturing us to the professional ambitions of medicine. The point must be emphasized that medicine has not been greatly successful in raising the standards of health across the community. On the contrary, history has shown a different view.(6) However, the image and status of medicine are such that its promises to rid us of this disability and that discomfort have seemed immediately plausible. Thus, the elite position of the profession is assured and many opportunites for further expansion are gleaned from its promissory image of a bio-utopian future.

Viewing medicine through a Foucauldian perspective is to be less concerned with social consequences that may result from specific biomedical achievements and more aware of the pan that the medical technocrat plays in directing social and government policy in matters that affect the individual's general life chances. A Foucauldian approach is less interested in determining whether widespread use of fetal testing is an incipient form of eugenics or a utilitarian necessity brought about by most governments' shrinking budgets on long-term welfare spending, and more interested in asserting that these developments are not new but only a further step on a well established trajectory. Medicine in the West has grown by increasing its experimental field. As more ailments are "discovered," e medications and treatments are developed and more individuals are brought within the domain of medical practice, so the status and privilege of the profession has expanded, often in advance of its proven technical capacities.(7) Such an expansion of activity provides opportunities for meeting other professional self-interests, such as ensuring research and development funds from the public purse. However, technocrats remain largely unskilled in recognizing the full social and political consequences of their professional work. To allow them a privileged position is to entrust the future of society to those who have acquired the power to change society by virtue of their professional competence as technicians. The current revolution in biomedicine must be recognized not simply as offering clinical advance, but as simultaneously providing for the expansion of medicine's role as an agent of social regulation.

Power and Technology

Foucault describes the scientific advancement of the West as a "technological take-off" that began with the intermingling of social and political power with technical developments in the seventeenth century.(8) This new style of power, based upon technical and managerial knowledge rather than juridical and monarchic power persists today, as Robert Bellah has argued.(9) Power produced through technology is a form of power arising from an ability to cultivate and satisfy specific interest, values, and desires. Such power is nonnative, cultural, and opportunistic insofar as it privileges the needs and desires of certain groups and individuals. The consumer's need or desire for a service or product subsequently becomes the means by which those providing the services or goods gain advantage. When exclusive possession is held over a desirable commodity a situation of domination is created. Those providing the desired service can determine the circumstances of its availability, underscoring the fact that the interests of providers and clients are often very different.

This has been the case with donor insemination and in vitro fertilization made available only to those considered appropriate recipients, and it may soon be the case with genetic therapy. In these situations, the different interests of provider and client are not commonly represented as being in conflict. Indeed, the inherent power and domination of the situation are disguised insofar as the monopoly created by specialist knowledge has been legitimated by sanction of law and professionalism. In the normal transaction between consumer and provider the consumer does not feel exploited by the provider's monopolization of knowledge nor abused as his or her experimental subject, because the desire for the product or service has been publicly cultivated while its cost, in monetary and moral terms, has not been so broadly debated or examined. It becomes apparent that the power of the medical profession is greatly enhanced by developing consumer desires for therapies and interventions prior to perfecting them technically. The short history of in vitro fertilization (IVF) is a good example. Only now, more than a decade after the first successful IVF birth, are we becoming aware that IVF techniques are not capable of correcting infertility as promised.(10) Nonetheless, publicizing medical achievements and ambitions, as with IVF, has created a consumer public that continues to provide the opportunity for the extension of medical dominance.

Power is a strategy of relations that gives some individuals and groups the ability to act and keep acting for their own advantage. Power is also the ability to bring about a desired situation, and to prevent the actions of any who would oppose or thwart such desires. When knowledge becomes a source of power, as it does with technical or formal knowledge, it is the technocrat, the owner and controller of knowledge, who gains social power. Significantly, when technical knowledge is the basis of power, the inequalities between provider and consumer are frequently concealed by the idea that a professional service is offered.

Steven Lukes has argued that this definition of power is extremely subtle because it can direct individuals toward actions the eventual outcomes of which will not necessarily be to their advantage. Such power is also the most difficult to identify because it conceals long-term consequences with immediate satisfactions. For example, the public face of medicine is, in the main, benign and humanitarian. Medical professionals declare their interests to be the same as "everyone else's," say, to correct infertility or lid the world of disfiguring and disabling conditions. However, on the road to this bio-utopia, the technocrat needs a great deal of license to experiment and develop costly technology, and embodied in this license to act is the opportunity to accumulate social power, specifically, in deciding which conditions and disabilities will be stigmatized, which will be remedied, and which populations will become the experimental subjects used in the future development of the field. Biomedicine's promise to alleviate human flaws and undesirable traits at the same time is a mechanism by which power is consolidated within a technocratic class that exercises an administrative hegemony and is immensely privileged over biomedicine's consumers. As Lukes notes, latent conflicts and contradictions exist "between the interests of those exercising power and the real interests of those they exclude," that is, consumers.(11) It is also an instance of "structural violence," in that disadvantages are perpetuated by a legitimated social structure.

Biomedicine and the Medical Gaze

With the promise of human perfectability through technical means, the biomedical industries position themselves strategically within the everyday world of the individual. Biomedicine's detailed search of the genetic structures of individuals is presented as a great humanitarian achievement, but it can also be considered an extension of what Foucault has called the "medical gaze," bringing about an even more comprehensive surveillance of the individual body.

As we learn to expect of medicine greater accomplishments, we must be ready to grant the profession a greater license to penetrate us. Foucault has identified this increased scope of the "medical gaze" as the principal means of locating social power within a technocratic elite. He has argued that in our society power has been accumulated through surveillance: individuals are being observed more extensively and brought under the "eye of power."(12)

Our society is increasingly subject to the "inexorable logic of quantification, examination, and classification" and it is by these mechanisms that surveillance has increased,(13) a phenomenon well illustrated by conventional medical practices. As medicine becomes more technically sophisticated and more capable of sub-clinically mapping the courses of illnesses and genetically locating the sites of human disability, it also becomes more definite in prescribing human capacities, of recommending how people should and could look, behave, and function. Increasingly, the value of the citizen as a worker, student, parent, welfare recipient, professional athlete, and so on will be measured by his or her capacities, say, to perform certain physical and mental tasks, or resist specific illnesses and degenerative conditions, or withstand dangerous occupational environments.(14)

In modem society we have become accustomed to the frequent measurement and calculation of our abilities and characteristics by various social institutions, whether in the form of educational assessments or the more innovative genetic screening of workers to determine job suitability.(15) We are becoming increasingly accepting of an ethic of human accounting; that is, of accepting prescriptive standards about how people ought to behave and appear. Freidson has noted that these same managerial methods fit elegantly with conventional medical procedures.(16) In consequence, as everyday life becomes more closely calibrated by technically defined standards, we may become less tolerant of those who deviate from the norm or who violate standards. Those who do, for example, the obese, illiterate, epileptic, hemophiliac, and so on, are made responsible for eliminating or controlling their own disability. The attitude is that these individuals are an unnecessary financial burden to the community: their conditions can be remediated or eliminated and this is what should have happened.(17)

Foucault has drawn attention to the process of normalization through which certain attitudes and practices come to prevail as normal and acceptable.(18) It is principally through discourse, that is, through the ways in which systems of knowledge are established, expectations of human abilities discussed, and subjects and practices described in the working literature of a professional group, that the "normal" is defined.(19) So, characteristics that can be medically treated are now defined as pathologies: for example, infertility, baldness, obesity, hyperactivity, anorexia, premenstrual tension, postpartum depression, and a host of others. As genetic therapy becomes more commonly discussed in the popular media, we may be induced into expecting and accepting medical activities in this field. By popular discourse, genetic flaws are being redefined into sites of medical intervention. If Foucault's analysis of the history of medicine is correct, questions about the possible results and benefits of biomedicine will be deflected from the moral debate and translated into a preparatory rhetoric from which opportunities for genetic research and other technical developments are made more plentiful. Once again we will see medical expansion taking place on the basis of technical capability rather than explicit moral judgment and debate.

Much is made of the idea that medical advances take direction largely from consumer demands. Following the analyses of professional power by Eliot Freidson, Lukes, and Foucault, however, we can see this position as essentially naive.(20) Medical practices may embody interests quite distinct from those of its consumers, as is well illustrated by the economics of health. For example, current efforts to privatize medicine and biomedical ventures by governments, pharmaceutical manufacturers, shareholders in biomedical companies, investment traders, and so on, are propelled by the promise of profitability. Research is directed toward those areas that promise large financial rewards, and the therapeutic value of the research is made secondary to its market potential.(21) Ruth Hubbard has argued that these research opportunities are being regarded as "the new gold rush."(22) The competitive search for an AIDS vaccine provides a vivid illustration of the ruthlessness of the commercial factor in biomedical research.(23) So, while the public may consider that its demands for the products of biomedicine are a factor in shaping the directions these industries will take, it is more accurate to regard biomedical expansion as a response to a rationalistic and calculating ideology common to industrialized societies where profitability most often over-shadows merit.(24)

Biomedicine as Bio-Politics

Bio-politics is about how medicine comes to be in the business of policing societal expectations and of imposing certain standards of performance upon the individual. Modem medicine finds itself capable of acting as such because we have tacitly agreed that to be a normal member of society is to be surveyed and measured by a calculating medical eye. This medicalization is, according to Foucault, a mechanism that erodes the status of the individual while it simultaneously consolidates the power of a professional, technocratic hegemony. This encroachment of technology into everyday life is, in Foucault's view, the exercise of bio-politics.

According to Foucault, medicine is a mode of applied sociology-its interests are essentially to do with maintaining a specific social order in which it can flourish. By referring to this exercise of power as bio-politics, Foucault has rightly brought attention to the covert institutional processes by which individual life is valued. When goods and services such as high technology medicine are made available to the individual only insofar as they help to consolidate the domination of certain elite professions in society, then the publicized image of benevolence and the ethic of progress supposedly carried by technological advances must be viewed more critically. Foucault's concept of bio-politics rightly forces us to consider whether biomedicine is the proper means for ensuring a better, more equal and humanitarian social order as the bio-utopians have predicted.

A Foucauldian reading of biomedicine illustrates how certain human conditions have been redefined to create those discursive opportunities that consolidate social power in the professional segments of society. Human infertility, for example, has been recast into a correctable condition and infertile individuals are pressured to have their condition treated by technical means even though the success rates of medical intervention in this area remain significantly low.(25) The desire for this and other services such as the treatment of obesity, the sex selection of the fetus, the correction of physical signs of aging, the elimination of genetically transferred diseases and so on, create a population in need of continual medical servicing. A Foucauldian reading of biomedical practices shows that the significant accomplishments of medicine are not vastly improved health standards, as the image of the profession suggests, but rather consolidation of its professional hegemony. Modem medicine has been enormously successful in recruiting clients, and in dispensing moral regulations that define what is humanly normal and acceptable. Medicalizing a vast array of human characteristics has been instrumental in promulgating an insatiable desire for more medicine. One consequence is that the biomedical search for correctable human characteristics, and the ideology of human accounting inherent in this search, has been entirely compatible with the propagation of a technocratic order of society.
(1) Edward Yoxen, The Gene Business: Who Should
Control Biotechnology? (London: Pan Books,
(2) For a bio-utopian view, see Gus Nossal,
Reshaping Life: Key Issues in Genetic Engineering
(Carlton: Melbourne University Press, 1984).
(3) Ruth Hubbard, Embryo and Gene Manip
-ulation," Society 19:4 (1982), 47-50.
(4) Michel Foucault, Madness and Civilization: A
History of Insanity in the Age of Reason
(London: Tavistock, 1971) and The Birth of
the Clinic: An Archaeology of Medical Perception
(New York: Vintage, 1973).
(5) Nossal, Reshaping Life. See also Ellis Downs,
"Designer Destiny," New Society, The Sunday
Times (London), 19 February 1989, F5.
(6) See Thomas McKeown, The Role of Medicine
(Oxford: Blackwell, 1979) and Lesley Doyal
with I. Pennell, The Political Economy of Health
(London: Pluto Press, 1979).
(7) Louis Waller, "In Australia, The Debate
Moves to Embryo Experimentation," Hastings
Center Report 17:3 (June 1987), Special
Supplement, 21-22.
(8) Michel Foucault, Power/Knowledge: Selected
Interviews and Other Writings, Colin Gordon,
ed. (Sussex: Harvester Press, 1980), 119.
(9) Robert Bellah, "Social Science as Practical
Reason," Hasting Center Report 12:5 (October
1982), 32-39, at 33.
(10) Marsden Wagner, "Is In Vitro Fertilization
Appropriate Technology?," Report of World
Health Organization (forthcoming).
(11) Steven Lukes, Power: A Radical View (London:
Macmillan, 1974), 24-25.
(12) Foucault, Power/Knowledge, 146-65.
(13) Bryan Turner, "The Practices of Rationality:
Michel Foucault, Medical History and
Sociological Theory," in Power and Knowledge:
Anthropological and Sociological Approaches,
Richard Fardon, ed. (Edinburgh: Scottish
Academic Press, 1985), 193-213, at 200.
(14) Bruce Jennings, Daniel Callahan, and Susan
M. Wolf, "The Professions: Public Interest
and Common Good," Hastings Center Report
17:1 (February 1987),3-4.
(15) Thomas Murray, "Warning: Screening
Workers for Genetic Risk," Hastings Center
Report 13:1 (February 1983), 5-8.
(16) Eliot Freidson, Professional Powers: A Study
of the Institutionalization of Formal Knowledge
(Chicago: University of Chicago Press, 1986),
(17)Erving Goffman, Stigma: Notes on the
Management of Spoiled Identity (Middlesex:
Penguin, 1963).
(18) Michel Foucault, Discipline and Punish: The
Birth of the Prison (New York: Pantheon,
1977), 304-306.
(19) See C. Keith Boone, "Bad Axioms in Generic
Engineering," Hastings Center Report 18:4
(August/September 1988), 9-13.
(20) In their famous examination of the culture
industries, Horkheimer and Adorno argued
persuasively that consumer demands are
constructed; after all, people do not know
what they want until they know what is
available. The mass media do not respond
to specific consumer interests but, instead,
deliberately manufacture their own market.
The activities of the medical/pharmaceutical
industries could be legitimately portrayed
in the same manner. See Max Horkheimer
and Theodor Adorno, The Dialectic of
Enlightenment (London: Allen Lane, 1973),
(21) See J. Maddox, "Malaria, What Price
Progress?," London Times, 9 April 1983, 6;
D. Mackenzie, "U.N. Takes Control of
World's Food Genes," New Scientist, 24
November 1983, 558; also Thomas Murray,
"Ethical Issues in Genetic Engineering,"
Social Research 52:3 (1985), 471-89; and "A
Profitable Slice of Life," The New York Times,
23 August 1981, E7.
(22) Hubbard, "Embryo and Gene Manipulation."
(23) Marlene Cimons, "Bad Blood," The Age, 5
July 1986, 7 reprinted from the Los Angeles
(24) Graham Scambler, "Habermas and the
Power of Medical Expertise," in Sociological
Theory and Medical Sociology, Graham
Scambler, ed. (London: Tavistock, 1987),
165-93. See also Amnon Goldworth, "The
Moral Limit to Private Profit in Entrepreneurial
Science," Hasting Center Report 17:3
(June 1987), 5-10.
(25) Patricia Spallone, Beyond Conception: The New
Politics of Reproduction (London: Macmillan,
1989). See also Jocelynne Scutt, ed. The Baby
Machine (Melbourne: McCulloch Press,
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Author:Finkelstein, Joanne L.
Publication:The Hastings Center Report
Date:Jul 1, 1990
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