Sick chic

By Stephen Bowler

A public health emergency puts powers in the hands of state actors that are more usually reserved for times of war. Civil society is suspended and the normal rules of political economy overturned. Extraordinary times justify exceptional measures.

One of these exceptions is the bypassing of the doctor-patient relationship as the state assumes the role of doctor-in-chief, diagnosing and prescribing directly to the public. The discrete privacy of the consultation room gives way to prime-time pronouncements on TV. Patient-centred practice gives way to population level modelling. All in the name of health.

A public health emergency is always a political emergency because it radically reconfigures the relationship between state and citizen. The rational legal subject, free before the law, suddenly finds himself in the same relation to the state as he would to his doctor; that is, as a biomedical object with a duty to be well – but with the crucial difference that authority of diagnosis and prescription now rests with the public health state and not the personal doctor. In this situation the norms of informed consent are vitiated, for the simple reason that consent has become a policy objective and conformity a moral-legal good.

The freedom of the individual before the law is often understood in terms of juridical norms experienced in the realm of civil society. For good reason do we presume and cherish the temporal and moral integrity of contracts drawn up between reasoning adults within a stable body politic. Trust depends on no less.

Prior to this order, though, is another; the unique capacity to know and name the part of nature that we are; to understand the self as an object among objects as well as the locus of subjectivity. At this more vital level is freedom most fundamentally constituted, in the struggle to bring the universality of spirit and the particularity of flesh into meaningful unity, the better to forge a stable sense of self.

For we moderns, corporeality is not a second-order quality or somehow at odds with the agency it enables, but the very heart of person-hood, which – like the heart itself – is ineffably dual. The self sits neither in the being or the having of a body, ‘but in the impossible tension between these two versions of bodiliness, both of which are phenomenologically just’, as Terry Eagleton puts it.[1] For Philip Rieff, ‘what man suffers from finally is no more than the supremacy of spirit over flesh than of flesh over spirit; it is the dualism that hurts.’[2] The truth is always in the singularity, that we are neither minds nor bodies but both, ‘Historical as well as histological’[3] beings that can no more be cleaved from our organic integument than reduced to it. And such tensions as are within us are also without, in relation to a wider nature – the power of romanticism, for example, consists precisely in this dialectic, between the part of nature we are and the part that we are not. And each side of the equation must remain a kind of fiction if the whole – the singularity of selfhood – is to have any meaning at all.

All of which takes us into deep water. But here I want only to dwell on the way in which the doctor-patient relationship services the duality we are, a duality in which physical and metaphysical cannot be meaningfully separated. Like all other life forms we suffer and die, but unlike any other we can name and know our fate and on occasion seek medical help to alleviate the worst of it. On such occasions we tend to be less than our full selves because whatever the organic ailment it can never be fully distinguished from the subjectivity with which it is synonymous. To become a patient – that is, to be patient, to wait for the outcome that agency cannot engender – is to entrust your embodied self to biomedical authority in the hope that suffering might be relieved and normality resumed. And in that process of becoming a patient – of entering the sick role[4] – a tacit, unwritten contract is drawn up, a contract allowing for your very duality to be weighed in the balance.

There are, of course, many and various exceptions to this general rule, but it is the general pattern of doctor-patient relationships with which we are concerned, the overarching ethos of biomedical practice that is – arguably – the jewel in the crown of Enlightenment. It is in this crown that the duality running through each-and-every one of us is reconciled as a totality, as way of knowing who and what we are that is not at odds with itself, that reconciles the telos of our subjectivity with the evolutionary circularity of our biological corporeality.

Except it isn’t and it doesn’t. Or, at least, we grope our way forward, each with our own map and compass, all vaguely lost, all looking for the summit. As Alasdair Macintyre[5] so brilliantly understood, the absence of a shared understanding of virtue in the modern era – of a horizon of meaning that we can all agree is good and true – leaves us spectacularly free to forge our own forms of the good and then wield them against each other. With no metaphysical authority above us – no larger frame of reference to order the chaos below – we instead conjure a magisterium out of a sensorium and leave the rest to chance. And what more immediate expression of sensory experience than the body, the object among objects that is also our subjectivity?

Again, we’re in deep water, but the point is the way in which the doctor-patient relationship services the duality we are. One could say the same of any modern institution, of course, but no other is more intimately embedded in the realisation of modern personhood than biomedical science, the remit of which is the relief of suffering.

Suffering, though, is a mystery; a quality without quantity, the relief of which can be adjudged only by the subjectivity that is its etymological and ontological sibling. The relief of human suffering is a most delicate undertaking, rightly tasked to those with skill and insight, those who know fear in a handful of dust but also hope in the face of a new-born. In pre-modern times such sagacity was theological and suffering a subset of a cosmic telos. But when the Aristotelian roof fell in and a Cartesian cathedral of meaning erected in its place – the shifting of the Archimedean point, as Hannah Arendt[6] put it – suffering as much as sovereignty were effectively privatised. Body and soul were no longer His concern, but ours.

Through the modern era the authority of biomedical science has been embedded within this discourse, maintaining ‘health’ in largely functional, somatic terms, with psychic, existential dilemmas remaining the responsibility of free willing, rational-legal subjects. Many and various attempts to bring both sides of the equation into a closer alignment have been advanced, all of them tending to expand the remit of the therapeutic state[7]. But in amongst these attempts the doctor-patient relationship has remained more-or-less constant, with the former policing the sick role and the latter consenting to its strictures, all underwritten by Enlightenment progressivism.  

If one is in any doubt as to just how deeply this arrangement runs and in what terms the Cartesian contract is written, one need only pause and consider the – still discomfiting – fact that the desire ‘to please’ within the therapeutic envelope remains the most confounding variable of all in terms of proving what does and doesn’t work. The placebo effect suggests that allopathy, before ever it can become a method, is pre-eminently a relationship. Superficially a dyad of doctor and patient, in essence it is the wager between cultural and natural selfhood. The desire ‘to please’ without is founded upon an ability ‘to please’ within; a capacity so strong and constant that any clinical intervention worth its salt must be proven in terms of double-blinded, placebo-controlled, randomised trials, the Gold standard of medical research.

But the duality needs a centre, a narrative of human flourishing that is more than bare life[8] or utilitarian calculus, even if it isn’t a Greek city state. Absent the binding narrative and the parts take on a destructive life of their own: the tragedy of ‘trans’ being the most recent example. And with this long, withdrawing roar the precious jewel in the crown of Enlightenment that was the elementary hope that organic disorder might not be allowed to overwhelm existential order is undermined. Never mind that such techniques of the self were socially constructed, if not entirely iatrogenic; the relief of suffering that is – or should be – the raison d’etre of modern medical practice is corrupted when it forsakes ‘humanism for hominism’ by regarding us merely as ‘objectively perceptible nature’.[9]

When perfectly fit and healthy persons are urged to ‘act as if you’ve got it’, and perfectly fit and healthy persons, including children, are recast as asymptomatic vectors of disease and coerced into fearing nothing less than everyone else, then the suffering subject in question is the whole population. Ever since ‘fright night’[10] (23 March 2020) the demos itself has been ‘nudged’ into the sick role, pathologizing an entire body politic. Sickness has not just been nationalised but made fashionable – chic almost – as a means to a political end. The old paradigm might have had its disciplinary function, but at least it incentivised health. Now we are all equal and all sick. And the tragic truth of the matter is that in the UK – where the NHS is the closest we get to a national religion – the government has been wildly successful, inverting the notion of health as functional norm through a consciously promulgated campaign of fear. The golden rule, to ‘do no harm’, has given way to the utilitarian maxim of the greatest good for the greatest number; meaning that perfectly healthy people will be harmed, whether they like it or not. The sick role is not just expanded but collapsed; from a duty to be well in order to re-enter society, to a duty to pretend you’re sick, even when you’re not.

This is the key to understanding the depth of the crisis we are now experiencing. The locus of ontological integrity – the body – that has throughout the modern era been understood as a synonym of the self, is now increasingly represented as a biohazard in need of risk management. Such a representation has been aided by the waning of the doctor-patient relationship as we knew it and the waxing of the public health function as a tool of government policy. The elaborate symbolic order of the doctor-patient relationship that has, in the past, had an explicit duty to do us no harm and protect our privacy, precisely because we are at our most vulnerable when in its presence, is being systematically reconfigured in more authoritarian terms, as one arm of the Leviathan that is the ‘biosecurity state.’[11]

No wonder so many people are dazed and confused, as the innermost dimensions of their being are thrown into turmoil by a process that posits nothing less than the nationalisation of suffering. Salvation, if it is to come, will consist in the ability to refuse all injunctions to ‘act as if you’ve got it’ and resist top-down, totalising versions of suffering. Just as freedom begins in the body, so can it die there, in the invitation to be sick.

Sept 2021

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[1] Eagleton 1996 The Illusions of Postmodernism p.75

[2] Rieff 1959 Freud: the mind of the moralist p.344

[3] Canguilhem 1966 On the normal and the pathological p.119

[4] Parsons 1951 The Social System Ch.X

[5] Macintyre 1981 After Virtue

[6] Arendt 1958 The Human Condition p.273ff

[7] Nolan 1998 The Therapeutic State

[8] Agamben 1998 Homo Sacer: Sovereign Power and Bare Life

[9] Jaspers 1952 Premises and Possibilities of a new humanism p.69

[10] Dodsworth 2020 A State of Fear: How the UK Government weaponized fear during the Covid-19 Pandemic

[11] Elmer 2021 Brave New World: Expanding the UK Biosecurity State through the Winter of 2020-2021