InSicknessandInHealth:Governingtheselfinthehospitalandtheclinic

Victoria,BC,Canada,April2009

Care&PatienthoodintheEraoftheGene

Dr Joanna Latimer, Professor of Sociology, Cardiff University School of Social

Sciences

PlenaryTalk

WhatIamgoingtodointhispaperisthinkthroughthecontemporarylandscapeof

health care, orwhatAdele Clarke calls a healthscape, one thatmakes explicit the

problemsandtheissuesforcareinafrankandprovocativeway.WithFoucaultIam

goingtofocusonsomeeffects.Theseeffectsmaybeintermittentintheiroperation,

but they are, I suggest, systematic and systemic because they extrude so may

possibilities:toomanybody‐personsseem,likedirt,tohavebecomeoutofplacein

themodes of ordering I am about to describe. And asMaryDouglas helps us to

understand,wherethereisdirtthereissystem.

OnmentioningthatIamgoingtogiveapaperoncare&patienthoodintheEraof

theGenecolleaguesinnursinghaverespondedwith–‘Ohwearenotteachingany

of thatyet’. But I amnotgoing to talkabout that–nursingcareknowledgeand

know‐howinthecontextofadvancesinbiotechno‐sciences.RatherIwanttothink

aboutwhathasbeenhappeningtocare inmedicinemoregenerally,andwhatthe

connectionsarebetweentransformationsincareandtheextraordinaryexplosionof

interestandresearchinthegeneticandbiologicalbasesofdiseasesandotherbodily

troubles.

So my talk here today in part draws out of and on from my many studies of

medicine, nursing and health care organization, including those with many

colleaguesandwithmyPhDstudents.ButitalsodrawsoutofwhatIhavecalledin

JayGubriumandJimHostein’sHandbookofConstructionistResearch,anemergent

critical tradition inresearchonmedicine,nursingandhealthcareorganization. As

such I do not speak so much as an individual but out of and as a part of this

emergenttradition,someofwhosefoundingauthorsareheretoday:CarlMay,Mary

EllenPurkis,TrudyRudge,SiobhanNelson,MaxineMueller.

Soletusthinkaboutthescaleoftheeffect.WhenIwasapractisingWardSisterin

the mid 1980’s at the Edinburgh Royal Infirmary, the clinical home of a world‐

renownedBritishMedicalSchool,no‐onethatIcanremember,andIwasincharge

ofaprofessorialwardwithallmyconsultantsdoublingupasclinicalscientists,ever

discussed the gene, or the molecular origins of any particular disorder. The

exception was a haematologist whose research specialism was the hereditary

conditionhaemophilia. Now,wherever I look, thegene,andothermicrobiological

processes are being explored for their involvement in pathology, and for their

potential in relation tomedical interventions.This isparticularly, ifnotexclusively,

true of the degenerative and chronic diseases of Euro‐American countries, the

diseasesofthewealthy,suchasdementia,thecancers,andsoon.Evenageingitself

asamicro‐biophysiologicalprocessisbeingreconsideredmoreandmoreasa‘part

of the problem’, and as playing an important role in the aetiology of many

pathologies.Maybesoonitwillevenbepossibletoputonadeathcertificatethat

someonehasdiedofoldage.Thisrepresentsahugeshiftformedicine:20yearsago

no‐onecouldbeseentodieofoldage,itwasn’tconsideredapathologyinitsown

right.

I want to think then about this huge shift, what some have described as the

biomedicalization or genetiziation of the clinic, for its significance, particularly in

relationtocare.

TheCurecareBinary

Letmebeginwithsomething I thinkyouwillall recognise. Akeydiscoursewithin

thelandscapeofmedicinerevolvesaroundthetropesofcureandcare.Inparticular

whatIwanttopointtohereisthe‘carecure’binary.

Figure1

Iamusingthetermbinaryverydeliberatelyhere.ThetermbinaryisfromtheLatin

binarius,meaninghavingtwoparts.Abinaryisthuscharacterizedbyorconsistsof

two parts or components; a ‘twofold’. I like this idea of a two fold because it

connects toDeleuze’s conceptualizationof the fold, andhowweare folded

intodifferentdiscoursesandtruthregimes.Abinaryisdifferentfromapolarity

or dualism – a binary implies connection and interdependence: critically, a binary

impliesrelationality. Forexample,abinarystar(Figure1) isasystemoftwostars

thatrevolvearoundeachotherundertheirmutualgravitation.Soratherthancare

andcurebeingunderstoodasadualism,wecanthinkofitasarelationthatworks

institutionallyaswellasdiscursively.

Thebinary ‘curecare’ thus helps informa set of practices thatwe canunderstand

looselyas‘medical’,andthatcirculatearoundthebody,themind,andmattersoflife

and death. In many ways this working between carecure offers a way to travel

acrossandbringintoplaythelife‐worldsofpatientsandofpractitioners.

Socareandcurecanbeunderstoodastwomajortropes,tropes incirculationand

thatcouldbereachedforandthathavethepowerto‘call’.WithFoucaultIwantto

stresshow it is the verymysteriousness andelusivenessof these terms, and their

relation, that gives them their potency – and that this binary relation of care and

cure,has importantorganizingeffects. This includesmaking itmuchmoredifficult

tosaypreciselywhereadivisionoflabourlies.LetmeelaboratewhatImeanhere:

2stories1ststoryI am just tidying up at the desk having taken the handover form the nightnurses. It is about 8 am when Ms Sparrow arrives to visit her post‐oppatientsfromyesterday. Igoovertojoinheratthebedsideofonepatientwho has had a pneumonectomy. Miss Sparrow kneels down on the floornext to the patients chest drain, stands up and tell s me it has beenincorrectly setup,with theendof thedrainage tube sitting just above thewaterlevel,thusallowingthepossibilityofairtoenteringthepleuralspace.Sheisfurious,amImortified.Iapologiseprofuselyandarrangeforthedrainto be changed immediately. As well as ensuring that the night staff areretrainedwithregardtochestdraincareImakesurethatinfutureontakingthehandoverfromthenightstaff, thenurse inchargeandthenightnursecheckallthechestdrainstogether.(Lifestoriesofalapsednurse,Latimer,inprocess).2ndstoryIt isProfessorPetrie’sward roundandwe travel frompatient topatient inthe usual way. We arrive at the bedside of a very frail elderly lady, MrsGallacher, admitted with collapse, heart failure and severe anaemia. Thehouse doctor has presented a history of the patient in the doctor’s roomprior tocomingonto theward.Fromthemedicalhistory thepatient isnotapparently on any anti‐inflammatory medication. I have not met MrsGallacherbeforeasIhaveonlyjustcomebackfromsomedaysoff.Isitdownnext toherandtakeherhandwhile thedoctorsaretalkingtoher. Inoticethatshehasveryarthritichands,swollenandred.Iaskherifshetakesanythingforthepain.Shesaysshetakeslotsofaspirin.ProfessorPetrieordersa barium meal. Of course, Mrs Gallacher probably has not thought thataspirinisamedication.(Lifestoriesofalapsednurse,Latimer,inprocess).

Figure2

Inthesetwomundaneordinarystories(Figure2),whoisdoingthecaringandwhois

doingthecuring–thedoctororthenurses?Eachactionslipsandslidesacrossand

betweenthebinarycarecure.

So I want to clarify that within this perspective of the binary curecare, medicine

emergesasall thepractisesandprocesses,peopleand technology involved in the

performance ofmedicine: medicine appears as distributed across many kinds of

practitioner, including nurses and doctors, physios, radiologists, and so on and so

forth.

WecanthinkofthebinarycurecareintermsofaMöbiusstripi(Figure3).AMöbius

strip ismadebytakingastripofpaper, twisting itonceand joiningtheends.Now

the strip has only one side and one edge. This can be demonstrated by putting a

pencil down on the strip, turning the strip under the pencil until the pencil line

returns to its starting place. Thepencil linewill appear onboth sides of the strip,

whichmeans, in effect, that it hasonlyone side. In the carecurebinary, care and

curetravelalongplanesthatendupasconnectedandonthesameside.

Figure3

As we have seen from my two stories there are possibilities for chiasms and

crossingshere.Theambiguityandambivalenceoverwhatcountsascuringorcaring,

allows forgreatmotility andkeepsopenpossibilities for shifts inperspectivesand

justifications.Forexample,howanactivityconstitutedascarecansoeasilyalsobe

seentohaveotherpotentialintermsofcure.

Figure4

Forexample, in figure4according to the titleof the image, amanwith leprosy is

weavingasapartofhiscarefollowinghiscure.Butofcoursefromtheperspective

ofoccupationaltherapy,occupationintheformofweavingitselfhasaffectsinterms

ofenhancingwell‐being.Weavinginthiscontextisinasensecurative.

NowofcourseIamofferingthebinary‘curecare’asinasenseanidealtype,butone

thathasitsorganizingeffects.ItisoneIthinkthatevenifwedon’tlongforit,weat

leastrecogniseit.

Therehavealwaysbeenproblemsforcarewhereabody‐personcannotbeheldon

the medical ground of cure, where they can be figured as Becker’s ‘crocks’, or

Jeffrey’s‘normalrubbish’:aspeopleforwhomnothingcanbedone,astrivia,oras

havingaswhatonenurseinoneofmystudiescalled‘noprospectaheadofthem’.

DameCiceley Saunder’s hospicemovement in the1980’s and IngunnMoser’s talk

yesterdayaboutdementiacare,andwhatshecalled ‘a logicsofrehabilitation’,are

examples that help expose how any body‐person‘s ills can be subject to care

practicesthatcontainwithinthemapossibilityforenhancement.Howforsomany

bodytroubles,particularlyinrelationtothosederivingfromchronicillnesses,cureis

itself is an unobtainable ideal if too narrowly conceived. Critically, in the curecare

binaryevenwithaso‐calledincurablediseasesomeonecanhavealife,theycando

morethanmerelyexist,includingtheprocessofdyingbeingitselfapartofthatlife.

NowIwanttosuggestthatwecanreviewthelandscapeofsocialtransformationin

healthcaresystems intermsofdividingpracticesthathave insertedandworkeda

riftinthebinary‘curecare’,andthatundermineitsorganizingproperties.AndIwant

to suggest that thesedividingpracticesalignandoverlap toperformconditionsof

possibility for the chasm between cure and care that we are currently struggling

with.

DividingPractice1:MedicalDominance

ThefirstofthesedividingpracticesthatIwanttopointtoiswhathasbeentermed

in the literature ‘medical dominance’. What everyone knows and understands is

thatthroughprocessesofappropriationandclosurethetermmedicinehasbecome

reservedforwhatdoctorsdo.

Here then the two entirely mysterious conceptions, care and cure, in a binary

relationtooneanother,throughthedividingpracticeofmedicalprofessionalization

begintobecomeseparated,disconnected.Specifically, inthereservingoftheterm

‘medicine’forwhatdoctorsdothereisasubsequentdivisionbetweencurativeand

caringpractices,betweencur‐iosityandcarefullness.

WecanseeinFoucault’sBirthoftheClinicthattheemphasisonknowledgeandthe

performanceofmedicineas sciencepushesandpresses thisdividingworkof care

fromcure,so thatcurebecomestheprerogativeof thedoctors,whilecareat first

seemstoberelegatedtothe‘para’‐medicals,particularlytonurses.Andinparticular

there is a possibility of making it seem that there is a separation of the work of

representing(assayingwhatis)fromtheworkofinterveningandtreatment,aswell

asfromtheworkofcaring.

And thisdivisionbetweencareand cure canbeplayedacrossotherdivisions. The

divisionofferedtousbyMikeFeatherstone(1992),forexample,betweentheheroic

and the mundane, with cure being associated with the heroic life, while care

becomesassociatedwiththeeverydaylife. Andacrossotherdivisions:suchasthe

division between cure asmasculinework, and care as femininework; or across a

divisionbetweenwhatDrewLederdistinguishesastheobjectbody(corps),andthe

lived body (lieb), with the object body the concern of cure and the lived body as

relegatedtotheworkofcare.

But as Ann Marie Rafferty helps illuminate in her book The Politics of Nursing

Knowledge, these practices of care and cure divide particularly over the issue of

claimstoknowledgeandtheproblemofwhatcountsasknowledge.

Critically, what governs the space of medicine as cure, is knowledge as science:

science as of a particular kind, associated with the scientific method. And this

governing of the domain ofmedicine by knowledge as science,means that other

practitioners, such as nurses, tomake theirwork visible as professionalwork, are

called tomake explicit how their work is also knowledge based. Here there is a

proliferationofresearchintothe‘care’partofthe‘clinical’domain–pressurearea

care, wound treatment, infection control and so on and so forth. Within this

perspective and rendering, care begins to be reconstructed, and effaced, as

‘intervention’.

Whatismuchmoredifficultinthespaceofknowledgegovernedbyideasofscience

isresearchonthoseactivities,processes,effectsandaffectsthatareinvisibletothe

scientificmethod,thoseaspectsofthemedicalworldthatare invisibletoso‐called

‘normal’science.

Whereknowledgeassciencegovernstheorderingofrelationsofrepresentation,the

cliniccomestobeorganizedhierarchically,intheFoucauldiansense.Thuswhatwas

onceabinary,curecare,underthesekindsofdividingpracticesbeginstobeplayed

out in a hierarchical relation, relations of what Marilyn Strathern (1997) calls

comparison. So that care begins to emerge as the supplement of, or even as an

inferiorsubstitutefor,cure.Iamthinkinghereofallthosesituationsinwhichcure,

increasingly narrowly defined, is not possible, so that all that is possible is that a

condition ismanaged. Here,minimal caremayarrive in the formof adifferential

diagnosis. Butaswillbeseen inthenextsection, increasinglythemanagementof

conditions constituted as incurable (such as diabetes, asthma, dementia, arthritis,

andsoon) isbeingpassedontotechnologiesofcare,orwhatBrunoLatourwould

callmachines.

DividingPractise2:AccountabilityasTransparency

Iwanttoturnnowtothematterofaccountability,intheguiseoftransparency,and

thedividingpracticesofwhatStrathernandothershavecalledauditcultures.

Whatstartstoemergeinanalyseshereisthatmanagementsciencedoesnotbelieve

inknowledge in thesamewayaswehaveseenabove. Rather, Iwant tosuggest,

thatmanagerialismwantstochangecultures. Here,theneedtochangeculture in

the domains of care and cure, partly arises from the elision between culture and

tradition,ideologyandideasthattheprofessions,particularlydoctors,areorganized

along tribal lines: it is the ceremonial order of the clinic that is the drag on

modernizationofhealthcare.Managerialismthusfindsanalignmentwiththesocial

science critique of medical domination. We can see this in Phil Strong and Jane

Robinson’sanalysisoftheNHSundernewmanagement.

Now what I want to suggest is that because of the displacement and hierarchy

betweencureandcareeffectedthroughthedividingpracticesofmedicaldominance

discussed earlier, transparency over what has been set aside as curing has been

differentfromwhathasbeensetasideascaring.Thedividingpracticesthatwehave

alreadyencounteredthuscreatesanarchaeology,asetofseamsand foundations,

along which accountability travels to create further rifts and cracks in the binary

carecure.

Put under the microscope of transparency medicine, governed by knowledge as

sciencehas togooff somewhereelse– far fromthebedside– toreassert itself in

relationtoknowledgeasscience.Otherwiseitisonveryshakyground.

Herewe can imagine that the first space formedicine as cure to retreat to is the

technology of the Randomised Control Trial and evidence‐based medicine: here

everything to do with intervention can be trialled. But what trials don’t help

medicine‐as‐cure to do is perform itself as beyond the pale of ordinary

accountability,thatisasrepresenting,asengagedinnormalscience:RCT’sdonotdo

the work of making medicine‐as‐cure visible as science, as discovery, as ‘real’

science. As Ian Hacking’s work has helped to show, the strongest grounds for

legitimating the need for intervention are those routed through the mode of

orderingofferedbyrepresenting:onlywhenmedicinecanbeshowntobeengaged

in representing ‘what is’, as engaged in normal science can it make itself

(un)transparent,andfendoffcallstoaccount.

Somedicineascureneededtoperformitselfasrepresenting,not just intervening:

doingthiscanmakemedicineascure(un)transparent.Somedicineneededharder

sciencetothatofferedbyRCTandthetechnologyofevidencebasedmedicine.Itis

hereIwanttosuggestthatmedicinehasrealigneditselfwiththegeneandthenew

biology.

Myargumentisthenthatitisamanagerialneedforaccountabilityastransparency

thathassentmedicinebacktothebasicsciences:alignmentsbetweentheclinicand

the newmolecular and reproductive biology offers firmer ground formedicine to

make itself (un)transparent as knowledge. In its realignment with the basic

biosciences,andareturntobiomedicine,medicinereturnscuretothewell‐travelled

wayofscientificmethodornormalscience.

Letsstoptothinkforamomentherehowmucheasieritistoclaimrevelationinthe

laboratorythanintheclinic.Herethereispromise,orasothercommentatorshave

suggested,hope,notforpresentinterventions,butforafutureofknowledge.Bio‐

medicalknowledgepromisesnotjustafutureknowledgeoftheoriginsofillnessand

diseasebutofthestuffoflifeitself.

Whatthealignmentoftheclinicwiththenewbiomedicalsciencesdoesiseffectan

evenmoreintensereduction,asEmilyMartinhaselaborated,ofnotjustillnessand

itsorigins,butofpersons,toeversmallerbodyparts.Thisreductionisofcoursethe

seduction:becauseitfocusesonthestuffoflifethenewbiomedicinedrawsthegaze

awayfromthecomplexityandmessof,forexample,socialmedicine.Thisisnotjust

to recognise that there is also a complexuniverse there, at themolecular level of

interacting stuff, but this complexity and unravelling at the molecular level helps

perform biomedicine as mastering nature, and the universe within. And as

transparencyandthedemandsofauditculturedrivemedicinebacktoscience,there

isreinforcementandintensificationofknowledgeasnormalscience.

Back in the laboratory, medicine as biomedicine appears more real, and more

transparent.Andwithinthisview,theclinicandthebedsideitselfareakeypartof

thelaboratory,asIhaveshowninmyworkonclinicalgenetics.Butbackhereinthe

laboratory,weareinastateofanticipation,standingonceagaininwhatHeidegger

callsadvanceoftheworld.Andhere,inthelaboratory,cure,thrustintothefuture,

is amillionsmiles away from care. Butwhat for themoment seems to be being

accomplished is the rebirth of the clinic (Latimer et al 2006) as a site for the

productionnotjusttheconsumptionofknowledge.

Within this view accountability serves as a dividing practice so that we can

understandbiomedicalizationnotsomuchasacausebutaneffectofaccountability

regimescomingintotheclinic,regimesoftruththat intensifythedivisionbetween

cure and care, so that the fissures and rifts become chasms: abysmal rather than

chiasmic.

Sowhathappenshere–totheotherkindsofmedicalpractitionersassociatedwith

care,andthesick,ratherthancure,andtothepeoplewhoarehere,now,back in

thepresent?

NowifwerememberwithStrathernthatculture,inthecultureofenhancement,is

seenasadrag,andwithmedicalsociologistsandmanagerialists,thatitisinstitutions

such as medicine that are at fault, then what is needed under regimes of

accountability as transparency are technologies that can deliver interventions as

standardisedandmeasurable.Sothatbackhereinthedaytoday,ascurehasgone

off to RCT’s and the laboratory, care has become increasingly technologised,

demoralised,anddeskilled.

Accountantsandeconomistskeepsayinghowexpensivecareis,andhowwefacea

futureofmoreandmoreneedforcareaspopulationsage.Sotransparencycallsfor

carenottomakeitselfvisibleasknowledgebased,thisisthemistakeofnursingand

othercareassociateddisciplines.Rathercareneedstobemadevisibleasefficient,

sothatcaregetsreconfiguredasprovisionandintervention.Herethemanagement

ofcareisheavilyinvestedinthenotionofplanning–protocolsandproceduresthat

can stand in advance of their delivery, and a distribution of care work amongst

personswhoatthepointofdelivery,reconfiguredasproviders,aremerelyfollowing

ordersprescribedelsewhere.Stafffollowproceduresandimplementplans.Socare

is relegated to what Latour in his book Science in Action nominates asmachines.

Indeed, what care, reduced to provision and intervention, needs now are more

machines.

Careincreasinglydividedfromcureneedstomakeitselfvisibleagainstmeasuresof

efficiency specified far from the space of care. Within this context care,

reconfiguredasinterventionandprovision,canbeincreasinglytechnologised,made

leanandefficient,independentofthepractitionerswhodeliverit.HereIamthinking

thenthatwecanseetheeffectsofaccountabilityandtransparencyandthedivision

ofcare fromcure, intheendlessproliferationandpursuitof technologiestomake

caremanageable:suchascarepathwaysforspecificdiseasesortreatmentregimes,

thenursingprocess,collaborativecareplanningandsoonandsoforth.

Care reconfigured as provision and intervention has been taken over by the

machines:machinesthatcanbeunderstoodasprogrammesforconduct.Thereare

evenmachines that act as centres of calculation for theneed for care: scales and

assessmenttoolsforweightingtheneedforcare.Onesuchisthetriagesystem.

Caremachinessupposedlyobviatetheneedfordiscretion.Withinthisviewconduct

–that,hasasIhaveshowninmyearlierwork,hasamoralorspirituallinking–and

themysteryofcare–issidelined.

Moreandmoreofthisroutinisedmedicine‐as‐interventioncanbepassedontoGP’s

and nurses, while the work of providing for the body now almost completely

amputated from the work of cure gets passed on to paid and unpaid carers and

moreandmoretopatientsthemselves.GP’sandnursespickupmoreandmoreof

the medical work once it has been embedded in the machines as pathways,

proceduresandprotocols.Andcaregetsreconfiguredasillnessmanagement,with

interventiondistributedacrossmanydifferentagencies.Ontologically,practitioners

are refigured as providers and patients as recipients. Except of course patients

themselves are increasingly implicated in health carework, not just as carers, nor

even as CarlMay has shown in his studies of telecare, as recipients, butwith the

workofwhatonceusedtobeassociatedwithcure:theworkofmedicalexamination

anddiagnosis.Ratherthisseparationofcureandcare,ofdiagnosisfromintervention

and so on and so forth, and the proliferation of machines, has intensified and

proliferatedmomentsof assessment and access for patients and staff a like. And

thisthecripplingmess.

Fromtheperspectiveofpatientsthereisaproliferationofthresholds.Herepatients

cannotrelyonthemachines,medicalandadministrative,toactastheiralliesand

spokespersons, rather they are called to thework of negotiation and justification,

particularly in circumstances where their bodies and troubles do not fit the

configurationof thesystemsas they find them.Forexample,AlexandraHillman in

herworkonEmergencymedicineshowshowpatientsmustperformthemselvesas

carefulinrelationtohowtheyuseservicesandasneedingtohavetheresourcesto

mobiliseaccountsthatwillhelpnegotiatetheiraccesstocare.Withinthisrendering

apartofcureandcarepatientsgetrefiguredasthepotentialenemiesofthesystem,

whilethesystemitselfrequirescare.Butthereareotherinsidiouswaysinwhichthe

apparatusesofaccountabilityandtransparencyaretransformingpatienthood.

Patienthood:Thejointingofefficiencyandmorality

Strathern suggests that what audit cultures do is joint efficiency and morality.

Alongsidethereconfigurationanddemoralizationofprofessionalworkthecultureof

individuallivesathomehasbeenchargedtoavertoratleastpostponetheneedfor

care or cure. Here the exercise of choice comes into play as a site for the

performance of a particular kind ofmoral order, one that concerns itself, like the

genetics clinic, with a future of health andwellbeing. Remember, present action

aimedatthefutureisverydifficulttorendervisible.

Individualsarecalledtoperformthemselvesaschoosinghealth.Heretheyaremade

responsibleforhealthinrelationtoboththestuffoflifeaswellasthestyleoflife.

So that care shifted into the home, remerges as choice. On the one hand

transparencycallsforpeopletoperformthemselvesasgoodcitizenswherecareof

self involveschoosingastyleof life inanticipationofa lifeofhealth: livewellnow

andbehealthylater(figure5).

Figure5

Andontheotherhandthealignmentofthegeneandtheclinicconstructsandcalls

for people to exercise choice over the reproduction of healthy bodies andminds

(Latimer 2007) (figure 7). Of course choice here is always prefigured and

preordered:theneedforchoiceaswellasthepossibilitiesofwhatwemightchoose

areassociallyconstructedasanythingelsethatwemake.Here,thegeneticclinicis

asiteofsocialengineering:helpingtoexciteasenseoftheriskinessofreproduction.

Figure6

Fromchiasmtochasm:wheretonow

Themysteryofthecurecarebinaryseemstometobeincreasinglyinthedark.

Accountabilityastransparencyinsertsthenewrationalismintopracticesofcareand

cure in ways that operate along the fracturing already engendered through the

dividing practices of medical professionalization and dominance. Transparency

intensifiesthetrajectoryofcureandmedicinetowardsbiomedicalization.Sothereis

genealogy here on how managing through notions of accountability come in on

existingdivisionsaroundknowledge,andthedivisionbetweenmedicineandother

practices.

Biomedicalization within this perspective is an effect of regimes of accountability

andtransparencythathavedrivemedicinebacktothelaboratoryandamillionmiles

awayfromcare.Atthesametimeascarehasbeentransformedintoprovisionand

intervention,distributed through thedevelopmentof technologiesofcareand the

machines of calculation. Discretion gets reinvented as negotiation, with a

proliferationof thresholds throughwhichpatientshave topass toaccesscareand

interventions. Asatthesametimeasmoreandmorehealthcare‘work’passesto

patientsandtheirfamilies,peoplearebeingincitedtoperformthemselvesasmoral

in their choices over their style of life and the stuff of life that they choose to

reproduce.

Sothatitseemsthataccountabilityastransparency,hasactedasadividingpractice

to reinforce the rift between care and cure inways that obliterate any hope of a

return to the curecare binary. Rather the care‐cure binary having chiasmic

properties,myfearisthatthereisnoreturn,thatanunbreachablechasmhasbeen

produced.Soquestionsariseastowherecanwegofromhere.

Aretherepossibilitiesforbreachingthechasm–buildingbridgesthatbringthetwo

banksbackintoviewaswhatHeideggerwouldcallalocale–aplaceforthecarecure

binarytodwell?Whatobjectscanbeputintocirculationtoretranslatetheeffects

ofwhatIhavebeendescribingabove? DavinaAlleninherworkonCarePathway

development seems to be suggesting that in the work of their construction care

pathway seem toact asboundaryobjects thatdo someworkof reconfiguring the

kindsofbreachesandchasmsthatIamdescribinghere.

OrwithAnnaMarieMoland IngunnMoser,wecankeep to the local and specific

descriptionsofhowamultiplelogicsofcareisatworkintheorderingofhealthcare

environmentsandmakemorevisiblewhenandhowtheseareoutofbalance:when

choice or efficiency or somatic medicine, for example, becomes too greedy and

dominates, to extrude other possibilities for interpretation and conduct. My

problem here is gracing the administrative nonsense of technologies of care and

calculation,orabiomedicineorientedtothefuture,withanideaoflogic,seemsto

betoogenerous.Mysuspicionisthatthisisaglossofsocialscience,andthatfroma

patient’s,andperhapsevensomepractitioners’,perspectives,thereisverylittlethat

islogicalabouthowcontemporaryhealthcareorganizationisworking.Myquestion

reallypertainsastowhetherwecanbegintothinkofthebreachitselfasaspaceof

possibility?

Figure7

In particular how can we revivemedicine, wrench it back from the future, and

interestitinthehereandnow,howeverdistributeditspractice?Helpitremember

itselfasapartoflife,asneverjustwork,orfunctional,butasworld‐forming?

While not wishing to undermine the suffering and pain sometimes involved, I do

wanttostressthatthefiguringofsickandillbodiesisitselfrelational,aninteraction

betweencertainkindsofbodiesandtheirculturalandsocialworlds.Soforexample,

peoplewithso‐calleddementiafindthemselvesinsocialworldsthattheydonotfit

(Schillmeier 2009), and this lack of fit between how they are, their body and the

worldmeansthattheyfindthemselvesasoutofline(MunroandBelova2009),allof

whichdoesnotjustintensifytheexperienceandthecondition(Schofield2008)but,I

would aver, partly constructs the condition itself (see also Kraeftner and Kröell

2009).Thisrelationalityalsoappliestothehealthissuesofthethirdworld:isaidsa

problemthatinheresinspecificbodiesorarelationbetweenpoverty,culture,global

economicsandthefleshandbloodofindividuals?

Questions arise then as to how we can bring into view methods, narratives and

discoursesthatcirculatedifferenceinwaysthathelpdeconstructtheoldhierarchies:

waysofimaginingthatrevalueboththesickandthefrail,andthecarethatsomeof

usrequire?IamthinkinghereofFlemingandMay’s(1997)paperinwhichtheystress

theimportanceofimagining.

Whiletherehasbeenanemphasisonexploringwaysofthinkingof‘spaces’ofcare,in

ways that privilege attention to issues of self‐determination, dignity, individuality,

privacy and choice, these do not address how care itself is relational and world‐

forming. Thestartingpoint then for reimaginingcouldbe topositadifferent, less

functional notion of care and the involvement of practitioners and patients as

embodied persons in relations (e.g. Rudge 2009, Savage 1995). Here we need to

undoalltheproblematicofthedividingpracticeofwork‐lifebalance:theworkpeople

doisasmuchapartoftheir lifeasanythingelsetheydoormake. MargaretMead

suggeststhattheverynotionofleisureisadominatingtropethatupsetstheideathat

howweworkalsodecidesourlives.

Specifically,wecouldbegintoimagineformsoforganizationembeddedinaviewof

carerouted in ‘body‐worldrelations’ (Latimer2009). Herespacesofcarecanbring

being‐with(mitsein)alongsidebeing‐in‐theworld(dasein),tothinkofspacesofcare

in terms of locale, materiality and relationality, rather than just in terms of

individualisation, face and self, as important as these are. But there are many

possibilitieshere.Let’stalkmoreaboutthem.Thankyou.

i TheMöbiusstripwasnamedafterAugustMöbiusin1885.