In my own terms, this marks the rise of the self of "self-care" — a paradigmatic self that experiences itself as responsible for its own well-being, morally compelled always to act with "due care" toward itself, morally obliged to avail itself of new biotechnological "resources," and, lest he be perceived as biting the hand that feeds him, to see these "resources" as "empowering," if not "liberating. Foucault's late study of medicine is found predominantly in Volumes 2 and 3 of The History of Sexuality series, The Use of Pleasure [ 12 ] and The Care of the Self [ 11 ], respectively.
His analysis deals mainly with medical technologies in the shift from Ancient Greece in the fourth century BCE to the Golden Age of Rome, the first two centuries of our era. More precisely, Foucault charts the historical shift in the human relation to medical technologies, in part, as one way to discuss what he sees as an increasing "problematization" of the self in antiquity and with obvious implications for the individuated self of modernity. For the Greeks, there was no "problem of the self," properly speaking: it would be wrong to speak of a Greek "self" in the sense that we understand this term.
Hence, medical practices in Ancient Greece did not constellate around individuated selves who would experience medicine as a "subjective" intervention in one's health or as a "technology of the self," as we do today.
Foucault summarizes: "I think that one of the main evolutions in ancient culture has been that this techne tou biou became more and more a techne of the self" [ 13 ]. Or even more succinctly, he writes: "I think that the great changes which occurred between Greek society, Greek ethics, Greek morality, and how the Christians viewed themselves are not in the [moral] code [i.
What I find remarkable about Foucault's historical study is how it reads today. The reader is invited to read a "history of the present" into Foucault's discussion. Our age of obsessive individualism cannot but resonate with the descriptions that Foucault offers of Roman culture, while our experience fails to resonate with the Greek. And so while for the Greeks, the question was how to live and live well, for Rome — and for us — life is no longer the "ethical substance" or the fundamental question, but selfhood is that substance.
Note the way the self operates as a trope in Foucault's discussion of Roman medicine: "medicine was not conceived simply as a technique of intervention, relying, in cases of illness, on remedies and operations. It was also supposed to define, in the form of a corpus of knowledge and rules, a way of living, a reflective mode of relation to oneself, to one's body, to food, to wakefulness and sleep, to the various activities, and to the environment " [ 11 ] emphasis mine.
This remains a compelling description of medicine and subjectivity today. What emerges from Foucault's study of medicine in antiquity is that since Roman times medical technologies have been used as a way for the self to work on itself. For the ancients, medicine was a solution to a certain ethical problem of the self, one answer to those social and political questions that an emergent self began to pose.
Medicine was one "place," as it were, where that self was elaborated, literally worked-out, when it asked questions about itself and its proper relation to family members and, more broadly, to society. Medicine began to offer a technical means by which the self would relate to itself, prescribing techniques by which that self would be recognized, would experience itself, as the good self.
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Medicine was therefore a novel aesthetics of existence, one way to break free of past modes of subjectivation, again, by promoting "a way of living, a reflective mode of relation to oneself, to one's body, to food, to wakefulness and sleep, to the various activities, and to the environment" [ 11 ]. In Rome, we might say that medicine freed the self.
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But today, I would argue, we stand in an opposite — and very much more sinister — relation to medical technologies. Stated in the most polemical terms, modern medicine does not liberate the self — it enslaves it. Today, medicine has become part of the problem of the self, and this becomes even more obvious in our genomic era of medicine: who or what am I if I am first and foremost a genetic self; what ethico-political responsibilities do I have to myself, to others, and to my offspring within this paradigm; and what subjective agency is left to me if the sovereignty of the Kantian "I" is displaced from a rational, autonomous self onto a sovereign genetic code that has the first and last word on who I am, what I am, and on who and what I shall become?
These are the new problems of the self in a genocentric age. Because genomic vocabularies have so pervaded the public sphere, it is impossible not to understand the self as a problem in these terms:. DNA in popular culture functions, in many respects, as a secular equivalent of the Christian soul. Independent of the body, DNA appears to be immortal. Fundamental to identity, DNA seems to explain individual differences, moral order, and human fate. Incapable of deceiving, DNA seems to be the locus of the true self, therefore relevant to the problems of personal authenticity posed by a culture in which the "fashioned self" is the body manipulated and adorned with the intent to mislead.
If DNA is nothing more than code, a "blueprint" or — better still — a "command" structure for the construction of protein molecules that, in turn, will shape who and what I am, we might well wonder: Who or what commands these commands? Where is the locus of agency? After all, I cannot be free from my genes.
At most, I can respond to my genes, after-the-fact. So, if selfhood or subjectivity are traditionally celebrated as the self's capacity to reflect upon itself, this self-reflexivity is now thoroughly undermined by our genes; the richness of subjectivity is displaced by, or, at the very least, dependent upon, the mechanistic world of the gene, a world governed by information, and not by thought. While we are thoroughly beholden to the terms of modern medicine, and while the self is interpellated as a subject of medical authority, medicine continues to sell itself as "self"-empowering.
We are still told that medicine is the cure to the problem of the self, the principal technology by which the self ought to relate to itself, through the body, through our relation with others infectious diseases , from the minutiae of our sexual lives STDs, infertility, healthy and happy sex lives, longer and harder erections Medicine is now the problem of the self; and medicine, we are told, is the necessary solution to the problem — a problem that this medical discourse has in fact itself secretly produced and systematically obscured e.
If medicine is angelic in its promise, it saves us on its own terms "obesity" and "infertility" are now diseases that medicine and pharmaceuticals promise to "cure". If anything, today an ethical project worthy of that name would strive to formulate new relations to medicine, new relations to the medical body, new relations to the soul that is constrained to think according to biomedical terminology and to act by perpetuating a medicinal ideology.
But the modern self remains constrained by a medical morality: I am morally remiss, my life is a life unworthy of living if I fail to submit to medical examinations, to doctors' and psychiatrists' recommendations, and to proactively minimize my risky behaviours and states-of-mind.
I am subject to medico-moral judgement if I fail to exercise "due care," if I neglect my self, if I do not live up to a level of self-care that is sanctioned by medical authorities, government agencies, insurance companies, employers, public health and occupational safety standards, family, friends, and concerned passers-by, who, with a glance, condemn me in my knowledge that this cigarette or cocktail is bad for me and violates life itself.
As Novas and Rose comment, the rise of this kind of pressure "reshapes prudence and obligation, in relation to getting married, having children, pursuing a career and organizing one's financial affairs" [ 15 ]. Of course, my "responsibilities" and very shape of these public moral expectations will multiply and shift according to each new biotechnological discovery. It is no longer adequate to follow the Hippocratic principle of "doing no harm"; today I must be proactive, I must do good, and consequently, "for my own good" I must accept on authority what the "good self" would do.
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Most self-care is undertaken by people independently of the involvement of health care professionals" [ 17 ]. The Government of Canada's public health agency, Health Canada, has defined self-care as follows: "Self-care [is] defined as the decisions and actions taken by someone who is facing a health problem in order to cope with it and improve his or her health" [ 17 ].
This description is found in an official policy paper. It is deceptive in its simplicity. It constitutes the individual as the locus of decision and action, reinforcing the ideal of the liberal subject so dear to biomedical ethics and liberal politics alike. Self-care presumes a rational, self-reflexive subject who is able to give his or her full — and "informed" — consent. The model relies on the principles of autonomy: either work to raise these individuals to the point where they are self-determining, or else presume them to be self-determining and act in such a way that will prove consistent with this presumption.
The problem with the latter, of course, is that these individuals are colonized by discursive models of selfhood and agency that are not, strictly speaking, their own. It is a form of hegemony. So while it would appear that the self of self-care is a self that relates to itself freely and transparently, with full knowledge, what proponents of self-care do not say is that this self-self relation is mediated and highly structured, relying on a cadre of so-called experts and technicians, deploying a vocabulary that is sometimes frightening, alienating, and often incomprehensible.
There is a "therapeutic hierarchy" that is in some sense inevitable, given the remarkable advances in medical research and the layperson's inability to develop such expertise. And yet this hierarchy is disavowed in favour of a self that is constituted as self-responsible. Responsibility is conceived in economic or entrepreneurial terms [ 5 , 15 , 19 ]: I, as a patient, am treated foremost as a client who employs expert-providers in my own health care initiatives, to improve my health, to work on my self as if I were not the subject of my own well-being but an object in need of repair or enhancement.
Here, the self-self relation is explicitly technologized, instrumentalized. The self relates to itself as through a knowledge economy — I am responsible to "know" my self biomedically, to take decisions and perform "best practice" actions in the project of my own well-being:. Responsibilization operates to individualize social responsibility for managing the risks of biotechnology.
Increasingly, individuals are expected, not to discipline themselves, but to manage themselves and the risks that they pose to the wider social good, through accessing and mobilizing the resources and expertise at their disposal in the genetic marketplace. If I fail to understand what certain risks might mean in real terms, in the terms of my own life, then that failure is somehow mine and mine alone.
Suddenly, she is no longer dealing with a "real" medical crisis, but with a potential one. In this gesture, she is quantified, reduced to a bare statistic [ 21 ]. Medicine can tell her nothing of the value of her life. She will be at a loss to evaluate the meaning of such personal risk, which she must now assume as her own, in the context of her entire life — a life whose value and duration are themselves impossible factors in the equation. She will be forced to make decisions with unforeseeable consequences, to navigate the unnavigable; every choice will have an existential valence. Even when we oversimplify her decisions, they remain impossible: should she or should she not undergo a prophylactic mastectomy and hysterectomy?
Or should she wait and see, and try to live fully under the veil of terror that such a diagnosis will carry with it?
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Sarah Lochlann Jain refers to this state as "living in prognosis" — "the collision between subjective life and objective death" [ 22 ]. In some ways, I suspect that such a life will prove unliveable, now that a positive value has been authoritatively assigned to her risk, based on statistics derived from genetic testing, average life expectancy, typical patient outcomes, and so on. Can we really speak of "informed choice" in this context? Her agency and autonomy are surrendered not just to medical authority, but to a future body-at-risk that is not fully hers, not yet.
She is a subject out of time, because "prognostic time constantly anticipates a future" [ 22 ] that may or may not include her. Where is her "I," that Kantian locus of subjectivity and reason and truth? And "who" will act, if she can at best react to the sovereignty of her elementary particles, to a future that is not yet and may never be in quite this way? Thus, while there is the ruse or at least the spectral promise of epistemic certitude in the rhetoric of self-care — indeed, a promise of biomedical scientificity — self-care fails to offer us anything like the good life and only inaugurates a self that, despite itself, can never be unequivocally good, happy, pure, wise, perfect, or immortal.
And yet we strive all the more, wedded to our epistemological worldview, where our own genetic matter is produced "as a field of management and includes practices such as mapping, testing, coding, banking, simulating, and representing" [ 20 ]. Despite this surveillance and perpetual self-management, the rhetoric of autonomy and freedom carries the day: it is our ideology, our mantra.
We presume the "autonomy of the self" because we cannot imagine an alternative. And such "autonomy" is also the cornerstone of political liberalism and the vast economies we have built. This emphasis on the autonomous individual effectively privatizes and depoliticizes what are properly social and political effects, embodied historical effects whose operational power is summarily masked and disavowed by liberalism. Challenging such autonomy, ethically or politically, is bound to be met with great resistance.
And so we continue to have faith in a self we describe as "free" to choose for itself, an indisputable source of its reason and will. Moreover, we glibly continue to conceive of our technologies as rational extensions of our autonomy, "extensions of man" in body and spirit — from medical technologies to weapons of mass destruction.
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And to complete this circle, we ardently believe that our technological developments actually increase our choices and, synonymously, our freedom. Those who understand freedom in this model tend to see freedom in neo-liberal or "free market" terms: for them, our political freedom is no more than the quantity of choice in our marketplace And so, to conclude this section, I argued above that the ethical basis of traditional liberalism — founded on reason, autonomy, and freedom — has been challenged and outstripped due to burgeoning biotechnologies.
In this section, I have argued that neo-liberalism founders for similar reasons; but in a more sinister twist, we are invited to discover an ethics of neo-liberalism in its presumed ethical neutrality — that is, neo-liberalism pretends to be ethically neutral by recasting reason, autonomy, and freedom as parameters of an independently fair and objectively equitable market. This, too, is a ruse, but of greater magnitude [ 5 , 9 , 19 ].
Socrates: "No physician, in so far as he is a physician, knows himself" a [ 23 ]. Here I would like to propose a different model of freedom and subjectivity, derived from Foucault's late work on ethics as "care of the self. I prefer to imagine the "care of the self" as a self-self relation that is inventive and open, as a self that questions the norms and constraints in and by which that self is said to be a self in the first place.
I see this intervention as a critical move away from a model of "self-care" and "the good self" toward a self that will be in a better position to question the good life. In order to explain the "care of the self" in greater detail, I will need to make a brief digression, to shift rhetorical registers somewhat, to de-familiarize our familiar and fixed ideas on care and medicine.
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