CONTENT:

This entry is prompted by SARS-CoV-2 (the virus) and COVID-19 (the disease), at least indirectly. The challenges of managing and arresting a global pandemic inevitably places a priority on biological pathogens and “population” health. This priority is clear in the dominant role played by doctors and epidemiologists in current news reporting. How, one may be tempted to ask, can WPR be deployed in this setting? What does WPR offer to those contending with “real-world” “disease”?

To engage with these questions, it is helpful to begin with some discussion of how a Foucauldian analysis approaches medicine. The starting premise of WPR is that “problems” are not pre-existing states or conditions but that they are produced in proposals. That is, proposals about what to do (how to conduct conduct) have implicit problem representations (Bacchi and Goodwin 2016: 19). The focus therefore is on the social and epistemological conditions that allow these problematizations to emerge. The goal is to draw attention to “the way we, under certain conditions, experience and articulate our ‘problems’ as well as our ‘solutions’” (Zwart 2002: 39). In a previous Research Hub entry (30 April 2020) Jennifer Bonham and I reflected on how the “problem” of “uncertainty” has been produced as a guiding premise in responses to COVID-19.

Turning to medical practice, a focus on how “problems” are produced as particular sorts of problems rejects a history based on the “consciousness of clinicians” in favour of determining “the conditions of possibility of medical experience in modern times” (Foucault 1973: p. xix). In this account, “What the ‘realist’ takes for (medical) ‘reality’ is a time-specific conception that is meaningful only on condition that the practice known as ‘clinical medicine’ is already in place” – that is, a practice that includes “a specific conception of disease, a particular relation to the body, diagnostic and therapeutic instruments and procedures, as well as institutionalized professional standards as key-elements” (De Vries 2002: 157).

“For example, when a physician tells a patient that his (sic) complaints about fatigue are symptoms of arteries in bad shape and that an operation is advised, this statement is meaningful only within the rules of the game we know as clinical medicine. … Two centuries ago “arteries in bad shape” was not a medical condition”. (De Vries 2002: 160; emphasis added).

The reference to “rules of the game” relates to Foucault’s position on “truth” and “truth games”. For Foucault (1985), telling the truth is like playing a game because, as in a game, there are no outside criteria by which to judge its content; “truth” is shaped by internal rules or “field assumptions” (see Research Hub entry 31 May 2020). The task then is to devise ways to tease out these “rules of the game” and to place their production “at the heart of historical analysis and political debate” (Foucault 1980: 47 in Castell 1994: 238). Annemarie Mol (2002: 50) develops this insight to emphasize how specific medical practices rely upon “embedded knowledges” to produce particular realities.

WPR undertakes the examination of the production of medical knowledge, including the conditions of its emergence, insertion and functioning, through a study of problematizations. Its seven forms of questioning and analysis (seeBacchi WPR CHART) draw attention to how medical “problems” are conceptualized and produced, drawing particular attention to the assumptions and presuppositions (the “field assumptions”) upon which such conceptualizations rely, to the uneven course of their development, and to their possible implications for how governing takes place. This form of analysis has a political goal – to enable us to consider how epistemological and ontological assumptions shape our “realities” and with what effects. To quote De Vries (2002: 161): “The success of Foucault’s analysis in making explicit what is implicit in clinical medicine may help us see what is implied in the practice that is under construction in current medicine”. Zwart (2002: 39) elaborates:

“By studying the conditions that allow certain problems and solutions, as well as certain principles and concepts, to emerge, we may become more aware of the factors that actually guide our thoughts and actions in the present. And this may prepare us for making our own concrete choices with regard to the present …”

Here and in a subsequent Research Hub entry I offer examples of WPR applications in the field of medical practice, indicating how these applications contribute to understanding the rules of the game of clinical medicine. I also suggest how the insights produced by these applications provoke lines of thinking that may encourage useful research on COVID-19 developments.

Murano et al. (2018) put in question the “problem-oriented approach” to growth hormone treatment for children with idiopathic short stature (ISS), which refers to children who are considerably shorter than average without identified medical reason. The authors characterize a “problem-oriented approach” as centrally focused on the “possible psychosocial disadvantages or problems of short stature and quantifiable height”, which, they argue, operates “at the expense of first-hand lived experiences of short stature and height as a lived phenomenon”. Their particular concerns are the ethical implications of such an approach.

Murano (2020) proceeds to use WPR to interrogate the contrasting ethical premises of FDA (US Food and Drug Administration) and EMA (European Medicines Agency) guidelines on the marketing of recombinant human growth hormone (hGH) for ISS. As Murano (2020) explains, she is not looking for errors or fallacies in the reasons advanced for or against approval of the drug but rather for norms, values and assumptions that underpin those rationales. We have here an apt illustration of WPR thinking, which looks to identify and question presuppositions that shape “problems” or, to borrow De Vries’ (2002: 161; see above) phrasing, to make explicit what is implicit in clinical medicine.  And, as with WPR, the objective is to reflect on the “broader implications that policies’ formulations might have on society”.

Usefully Murano draws on critical disability studies to interrogate the arguments/proposals she identifies. She explains how the FDA response illustrates a medical model of disability in which ISS is characterized as “a functional impairment or limitation, and as a problem inherent to the individual”. She shows that the EMA decision illustrates a similar epistemological approach: “it is not merely to treat short stature, but there is or might be a kind of short stature that might benefit from treatment”. Murano contrasts these positions to a relational model of disability, where “short stature should be understood not as an intrinsic problem of the individual (either in terms of height measurement or psychological well-being), but as a problem contingent on social discriminations and/or disadvantage”. In this stance, disability is not a fixed state or individual characteristic, but a process influenced by multiple external and internal factors: “This model takes as its starting point a human development model applicable to everyone and stresses the fact that development happens over time through a dynamic and complex process”.

This relational model, in which disability is constituted within a continuum of human experience, “reveals the many contributions that disability brings to the world and shows that medical intervention to change it or eliminate might not be justified” (see Garland-Thomson 2017). This stance on human development is taken up in work I have produced with Chris Beasley on “social flesh”, about which more will be said shortly.

Pringle (2019) brings WPR to an examination of Canada’s Assisted Dying legislation, supporting themes advanced in Murano’s work. She shows how the legislative framing of MAiD (Medical Assistance in Dying) in Canada fixated on a “reasonably foreseeable” death as a condition of its legal permissibility, “a gesture which was intended to protect vulnerable individuals from having their lives cut short by accessing assisted dying”. Such a proposition, argues Pringle, “inadvertently reifies the view that good healthy living necessarily excludes any kind of dependence or vulnerability”. As with Murano, then, in Canada’s assisted dying legislation, human development is underpinned by the “view that we are (or should be) autonomous and invulnerable throughout life, that a good healthy life is contingent on this invulnerability”. This autonomous healthy person could be seen to be linked to a form of neoliberal subjectivity with an emphasis on a moral responsibility to stay healthy (see Metzl and Kirkland 2010).

Currently in much feminist theory there is an emphasis on vulnerability and precarity (see McCormack and Salmenniemi 2016, and Koivunen et al. 2018). Pringle’s analysis raises qualms about the implications of identifying specific vulnerable groups and so reifying a human norm of invulnerability. Brown and Wincup (2019) deploy WPR in their analysis of the UK’s 2017 Drug Strategy to draw attention to the presuppositions and potential effects of being labelled (or not) as vulnerable. They argue that

“alongside bolstering targeted support, the problematisation of vulnerability in English drug policy supports the operation of subtle disciplinary mechanisms to regulate the behaviour of those deemed vulnerable, underplaying the role of material inequalities and social divisions in the unevenness of drug-related harms.”

Chris Beasley and I show how selected Australian policies rely upon a distinction between perceiving people as either controlled by their bodies (and hence vulnerable), justifying forms of regulation and constraint, or as in control of their bodies (and therefore robust, rational decision-makers/consumers, independent of government oversight) (Bacchi and Beasley 2002). Our examples (abortion, surrogacy, cosmetic surgery) all involve medical interventions, and hence provide important insights into the relationships between medicine/science and governing practices. We point to the deleterious implications of the “controlled by”/ “control over” dichotomy and offer social flesh as a new political imaginary.

Social flesh draws attention to shared embodied reliance, mutual reliance, of people across the globe on social space, infrastructure and resources. Insistence upon this shared reliance, we argue, underpins a profoundly levelling perspective, a radical politics (Beasley and Bacchi 2007), reopening vital debates about appropriate distribution of social goods, environmental politics, professional and institutional power, and democratic processes. It would be useful, I suggest, to explore the ways in which COVID-19 is commonly linked to “vulnerable populations” alongside the imperative for “autonomous” individuals to demonstrate “social responsibility”, and to consider how social flesh might disrupt these categories. Additional reflections on the implications of social flesh for the politics of COVID-19 follow in the next entry.

References

Bacchi, C. 2012. What Study Problematizations? Making Politics Visible. Open Journal of Political Science, 2: 1-8.

Bacchi, C. and Goodwin, S. 2016. Poststructural Policy Analysis: A Guide to Practice. NY: Palgrave Macmillan.

Bacchi, C. and Beasley, C. 2002. Citizen bodies: Is embodied citizenship a contradiction in terms? Critical Social Policy, 22(2): 324-352.

Beasley, C. and Bacchi, C. 2007. Envisaging a new politics for an ethical future: Beyond trust, care and generosity – towards an ethic of “social flesh”. Feminist Theory, 8(3): 279-298.

Brown, K. and Wincup, E. 2019. Producing the vulnerable subject in English drug policy. International Journal of Drug Policy, https://doi.org/10.1016/j.drugpo.2019.07.020

Castel, R. (1994). “Problematization” as a mode of reading history. In J. Goldstein (Ed.), Foucault and the writing of history (pp. 237-252). Oxford, UK: Blackwell.

De Vries, G. 2002. Pragmatism for Medical Ethics. In J. Keulartz, M. Korthals, M. Schermer and T. Swierstra (Eds) Pragmatist Ethics for a Technological Culture. Springer-Science+Business Media, B. V. pp. 151-165.

Foucault, M. 1973 [1963]. The Birth of the Clinic: An Archaeology of Medical Perception. NY: Pantheon Books.

Foucault, M. (1980b). I’impossible prison: Recherches sur le système pénitentiare au XIXe siècle. In M. Perrot (Ed.), Paris: Seuil.

Foucault, M. 1985. Discourse and truth: The problematization of parrhesia. In J. Pearson (Ed.), Evanston, IL: Northwestern University.

Garland-Thomson, R. 2012. The case for conserving disability. Bioethical Inquiry, 9: 339-355.

Koivunen, A., Kyrölä, K. and Ryberg, I. (Eds) 2018. The Power of Vulnerability: Mobilising affect in feminist, queer and anti-racists media cultures. Manchester: Manchester University Press.

McCormack, D. and Salmenniemi, S. 2016. The Biopolitics of Precarity and the Self. European Journal of Cultural Studies, 19(1): 3-15.

Metzl, J. M. and Kirkland, A. (Eds) 2010. Against Health: How Health Became the New Morality. NY: NYU Press.

Mol, A. 2002. The body multiple: ontology in medical practice. Durham: Duke University Press.

Murano, M. C., Slatman, J. and Zeiler, K. 2018. How sociophenomenology of the body problematises the “problem-oriented approach” to growth hormone treatment. Medical Humanities.  Doi: 10.1136/medhum-2018-011548.

Murano, M. C. 2020. A Disability Bioethics Reading of the FDA and EMA Evaluations on the Marketing Authorisation of Growth Hormone for Idiopathic Short Stature Children. Health Care Analysishttps://doi.org/10.1007/s10728-020-00390-1

Pringle, W. 2019. Problematizations in Assisted Dying Discourse: Testing the “What’s the Problem Represented to Be?” (WPR) Method for Critical Health Communication Research. Frontiers in Communication 4 (article 58). doi: 10.3389/fcomm.2019.00058

Zwart, H. 2002. Philosophical Tools and Technical Solutions: Comments on L. Hickman. In J. Keulartz, M. Korthals, M. Schermer and T. Swierstra (Eds) Pragmatist Ethics for a Technological Culture. Springer-Science+Business Media, B. V. pp. 37-40.