2. Outline
Subjectivation in
Foucault’s work:
1. Modes of inquiry
2. Dividing practices /
relations
3. Self-constitution
Subjectivation around
healthcare innovation:
1. Measuring healthcare
innovation
2. Electronic Health
Record policy and
relations in healthcare
3. Interaction with new
technologies
3. Measuring healthcare innovation I
Two traditions of innovation studies
• Mainstream economics: innovation as input to
increase productivity
• Evolutionary economics: innovation as output
of a production process, commercialisation of
new products
4. Measuring healthcare innovation II
Three reports
• RVZ (2001). Technologische Innovatie in de
Zorgsector. 01/05. Zoetermeer: Raad voor de
Volksgezondheid en Zorg.
• Scheepbouwer, A. (2006). Zorg voor innovatie!
Sneller Beter - Innovatie en ICT in de curatieve
zorg. The Hague: KPN.
• Ministerie van VWS (2008). Innovatie in preventie
en zorg. MEVA/AEV-2830484. 's Gravenhage.
5. Measuring healthcare innovation III
Three measures of productivity
• Diagnosis Treatment Combinations (DBC)
• “Function-oriented description”
• Quality-Adjusted Life Years (QALY)
6. Measuring healthcare innovation IV
Healthcare innovation, productivity and the
recipient of care
• “Principal subject”
• “Production subject”
02
“Principal subject”, “Production subject”
7. Electronic Health Record policy and
relations in healthcare I
Reciprocity in neoliberalism
• Abandoning social contract theory
• “Subject of interest” replaces “Subject of
right”
• Reciprocity between individuals, populations
and government by “spontaneous synthesis”
• Government manufactures freedom: strategic
programming of “entrepreneurs of the self”
02
“Principal subject”, “Production subject”
8. Electronic Health Record policy and
relations in healthcare II
Reciprocity in Electronic Health Record Policy
• The “principal subject” as partial solution for
collective problems
EHR prohibits medical mistakes
(“production subject”)
• Individual data for collective measurements,
collective data for norms for individuals
“Subject of reciprocity”?
02
“Principal subject”, “Production subject”
03
“Principal subject”, “Production subject”, “Subject of reciprocity”
9. Electronic Health Record policy and
relations in healthcare III
Resistance?
• Optional opt-out
• No information about
collective goals in the
information package
03
“Principal subject”, “Production subject”, “Subject of reciprocity”
10. Electronic Health Record policy and
relations in healthcare IV
“Immoderate” expectations
• Secondary use possible?
• Prohibiting medical mistakes possible?
• Etc.
“Subject of immoderate expectations”?
03
“Principal subject”, “Production subject”, “Subject of reciprocity”
04
“Principal subject”, “Production subject”, “Subject of reciprocity”, “Subject of immoderate expectations”
11. Electronic Health Record policy and
relations in healthcare V
Standardisation
04 “Principal subject”, “Production subject”, “Subject of reciprocity”, “Subject of immoderate expectations”
Healthcare
sector
Patient
Communication
(US)
I: Virtual record
II: Chain-integration
record
Information
(EU)
IV: Public
health record
III: Personal health
record
13. Healthcare
sector
Patient
Communication
I: Virtual
record
II: Chain-integration
record
Information
IV: Public
health record
III: Personal health
record
Scenario II: Chain-Integration Record
04 “Principal subject”, “Production subject”, “Subject of reciprocity”, “Subject of immoderate expectations”
05 “Principal subject”, “Production subject”, “Subject of reciprocity”, “Subject of immoderate expectations”, “Expert subject”
“Expert subject”?
14. Healthcare
sector
Patient
Communication
I: Virtual
record
II: Chain-integration
record
Information
IV: Public
health record
III: Personal health
record
Scenario III: Personal Health Record
05 “Principal subject”, “Production subject”, “Subject of reciprocity”, “Subject of immoderate expectations”
06 “Principal subject”, “Production subject”, “Subject of reciprocity”, “Subject of immoderate expectations”, “Expert subject”,
“Self-managed subject”
“Self-managed subject”?
16. 06 “Principal subject”, “Production subject”, “Subject of reciprocity”, “Subject of immoderate expectations”, “Expert subject”,
“Self-managed subject”
Healthcare
sector
Patient
Communication I: Virtual record
II: Chain-integration
record
Information
IV: Public health
record
III: Personal health
record
Electronic Health Record policy and
relations in healthcare VI
17. Self-constitution in interaction with
new technology I
Foucault on self-constitution
• Ascetic practices: writing, reading, speaking,
listening
• Institutionalisation and culture of self-
constitution
• Community, mentoring and institutionalised
practices
• Example of Zen
06 “Principal subject”, “Production subject”, “Subject of reciprocity”, “Subject of immoderate expectations”, “Expert subject”,
“Self-managed subject”
18. Self-constitution in interaction with
new technology I
Self-constitution at the Weight Watchers
• Forms of institutionalisation: Weight diaries,
group meetings, dieting mentors
• Framework of dominant discourses:
– Societal pressure to be slim and fit
– Feminist pressure to not subjugate to societal
expectations
06 “Principal subject”, “Production subject”, “Subject of reciprocity”, “Subject of immoderate expectations”, “Expert subject”,
“Self-managed subject”
19. Self-constitution in interaction with
new technology I
Technology-mediated self-constitutions
• Diary keeping in Electronic Health Record
“Self-constituted subject”?
• Online chat rooms:
– Critical reading and writing in online community,
resist medicine & geographical boundaries
– Invaded by medical specialists, abuse of online
visibility
“Subject of compromised self-constitution”?
06 “Principal subject”, “Production subject”, “Subject of reciprocity”, “Subject of immoderate expectations”, “Expert subject”,
“Self-managed subject”07 “Principal subject”, “Production subject”, “Subject of reciprocity”, “Subject of immoderate expectations”, “Expert subject”,
“Self-managed subject”, “self-constituted subject”08 “Principal subject”, “Production subject”, “Subject of reciprocity”, “Subject of immoderate expectations”, “Expert subject”,
“Self-managed subject”, “Self-constituted subject”, “Subject of compromised self-constitution”
20. “Subject of compromised
self-constitution”
“Principal subject”
“Production subject”
“Subject of reciprocity”
“Subject of immoderate
expectations”
“Expert subject”
“Self-managed subject”
“Self-constituted subject”
Thank you
Questions? w@woutermensink.nl
Editor's Notes
Let me start by saying that there was life before innovation. The discussion on economisation preceded the innovation debate by over a decade. The national electronic health record and the personal budget for healthcare were around long before they were adopted as measures to stimulate innovation. I will focus on the electronic health record for now. Question is what happens when existing policies get reinterpreted this way. For me, this question is particularly interesting if we look at it from the position of what we typically call the patient. Today, I will speak about the relation between innovation and what you might call the subjectivity of the one who receives care. After all, it is not trivial to consider someone a patient, instead of a consumer or a manager of his or her care. These are fairly obvious categories that lead to no surprise. What I will do is to try to open up this debate a bit more.
The French philosopher Michel Foucault made the making of subjects the overarching theme of his thought. Looking back at his life work, he distinguished between three modes in which people in our culture are made subjects. These three modes roughly correspond to the three ways in which I examine innovation in healthcare. First, Foucault talked about subjectivating people by using them as an object of research. He claimed that we are moulded by being classified through different forms of inquiry. He mainly looked at academia. I think it makes sense, however, to look at non-academic inquiries as well, or at places were science and practice come together. There have been many efforts to measure the impact of innovation, both in academia and in government. I particularly focus on the link that is made between innovation and productivity. I will try to shows how this impacts the patient. Second, Foucault discussed subjectivation by what he called dividing practices. In his historical studies, he showed how we came to distinguish between people that are healthy or sick, and between normal and abnormal people, to name a few. I want to broaden this useful idea of dividing practices a bit. I claim that Foucault spent serious effort on defining how relations in society are built. I think people are subjectivated in their relations to others. In terms of the case, policies that are dedicated to fostering innovation tend to be characterised by their attempt to change such relations. At the most basic level, the infrastructure for the electronic health record is expected to change the relation between the provider and the recipient of care. Provided with perfect information about developments in his or her health, the patient is expected to be able to speak to a doctor as an equal. The third mode of subjectivation is what Foucault called self-constitution. In his later work, he admitted he had focused too much on how people are created by others, mainly by scientific disciplines and governments. Even though Foucault was only outspokenly normative in interviews, it seems clear that he did not like the idea of being shaped by others. Obviously, he was aware that this is to a great extent inevitable. Nevertheless, he looked for ways in which we can shape ourselves as much as possible. He claimed that this was easier in antiquity than in our times. An important reason for that was that peopled learned to develop themselves. By daily practices, which Foucault described as ascetic, people forced themselves to take of themselves and of others. Keeping diaries and talking to friends are frequent examples. Recently, different scholars have started using this angle as a way of looking at developments in healthcare as well. I take this line of argument up, and connect it to the theme of technology and innovation. We can wonder, for instance, if the technologies that the healthcare innovation policy is supposed to stimulate can be used by people to shape themselves. I argue that this is possible to some extent, even though this is never self-evident and uncontained.
In order to understand what measuring healthcare innovation has to do with the positioning of the patient, we have to know a bit about the theory and practice of both innovation and healthcare. Due to time constraints, I need to brush over this in no more than a few sentences. I will start with innovation. Scholars have talked about the impact of new technologies for long. Still, innovation studies as a discipline is said to have started around the 1960s only. Even though disciplines like sociology and history have dealt with the topic as well, it largely developed within the confines of economic theory. Some distinguish between two traditions of thinking about innovation. The first is part of mainstream economic though. Here, innovation is regarded as the technical change of a production process. It is an input to generate higher productivity. The second tradition belongs to neo-evolutionary economics. Here, innovation is detached from productivity. It is no loner the input of a production process, but its output. Innovation is defined as the commercialisation of new products.
In the discussion on innovation in healthcare, the first tradition dominates. In Holland, this discussion started at the beginning of this century. However, it is clearly embedded in a longer discourse that some refer to as the economisation of healthcare. This is usually said to have started with the 1987 report of the Dekker committee. Before I get to the topic of measurement, let me explain how the first tradition of thinking about innovation is reflected. I mainly draw on three reports of the past decade. These were written by the Public Health Council (RVZ for the Dutch), the previous minister of healthcare Ab Klink and by Ad Scheepbouwer, the CEO of Dutch telecom provider KPN. These and other reports make it clear that innovation is considered as technical change in the process of care delivery. It is an input to increase productivity in different ways.
It is by looking at how the relation between innovation and productivity is measured, that the framing of the patient become clear. I present three types of measures that form a bridge between the theory and practice of both innovation and healthcare. The first measure concerns the productivity of care providers. I am talking about what we call Diagnosis Treatment Combinations. This financing system is based on an approach that was developed by American academics and care providers in the late 1970s, called Diagnosis Related Groups. A Dutch approach was introduced in 2005. It differs from the American one, in the sense that every new treatment receives its own combination. In order to get financed for an innovated care procedure, or a new drug, a Diagnosis Treatment Combination needs to be allocated to it. An organisation called DBC Maintenance has devised a set of indicators to measure the increased productivity of the innovated treatment. How the productivity of care provision relates to the patient turns out from a second measurement. With the recent reform of health insurance, the notion of function-oriented description was introduced. This has its roots in the Dekker plan. It does not prescribe which care provider a patient should turn to for receiving insured care. It merely describes the care function for which the patient is insured. This is expected to grant patient the power of demand. They are expected to operate as critical consumers who only contract innovative care providers, because they are more productive than others. The second way in which the position of the care receiver relates to innovation is indirect. The reasoning is that if care provision is more productive, then patients will be healthier and live longer. The result of this is that also they are more productive. This is indicated by the third measurement, which is called Quality-Adjusted Life Years. Again, this is a measurement that combines innovation and healthcare. This type of measurement was also introduced in the 1970s. A related type was popularised by the World Bank in the early 1990s. It measures the so-called health profit of a particular treatment. In the discussion on healthcare innovation, this was obviously turned into an indicator of the benefits of innovative treatments.
As we can see, the patient is related to innovation and productivity in two ways. On the one hand, he or she is placed in a principal-agent relation with the care provider. Let me call this type of care recipient the “principal subject”. On the other hand, he or she is expected to be more productive as well. Let me call this type of care recipient the “production subject”. In the first relation, the patient is granted power in relation to the doctor. In the second, he or she is the made productive by the power of the healthcare system. More types of subjects will follow throughout this talk. Let me keep a subject counter to keep track of them.
CLICK
As we have seen, the way in which innovation is defined in healthcare policy already sets some boundaries for establishing a different set of relations in society. We may wonder what happens with the actual policy lines that are proposed to stimulate innovation. The creation of a technical infrastructure for an electronic health record would be such a stimulator. The way of thinking about this infrastructure can be explained rather well by Foucault’s analysis of the rise of neoliberalism. He referred to different schools of economic thought that preceded what we now consider neoliberalism. In my interpretation of Foucault’s work, the most important element of the neoliberal way of thinking is a different conception of reciprocity. This is mainly because of abandoning the theory of the social contract. This 17th and 18th century theory more or less implies that the people conclude a contract through which they transfer a number of their rights to a government. In return for this they receive the benefits of the rule of law. Neoliberalism abandoned this judicial way of thinking for an economic one. Society is not run by contracts, but by the interaction of self-interested individuals. In terms of the subjectivity of the citizen, Foucault argues that we are no longer subjects of right, but subjects of interest. Reciprocity is no longer guaranteed by the law. Instead, it is assumed that there is a spontaneous synthesis through which the actions of self-interested individuals are also beneficial for the entire population. Collective goals are left to the state. The role of government is to make sure that the framework is set in such a way that there are no boundaries that prohibit free interaction between people. Governments must manufacture freedom. Free individuals ought to be strategically programmed to be entrepreneurs of the self.
I regard the infrastructure for an electronic health record as an example of setting such boundary conditions. It is set up in such a way that an implicit relation is created between the individual patient and the population. I name a few examples. First, the electronic health record is positioned as a tool for overcoming collective problems in healthcare. Waiting lists, the threat of the ageing population and the societal costs of medical mistakes are examples. Staging the patient as “principal subject” is offered as part of the solution. The health record would offer the patient the information to adopt this role with respect to his care providers. The collective problem that medical mistakes imply evokes the image of the patient as “production subject”. The electronic health record is expected to prohibit medical mistakes from occurring. As a result, the health of individual patients is assumed to improve, which makes them more productive. This is considered beneficial for the collective. The second example of an implicit relation between the individual and the population relates to the use of data from the health record. Particularly the Public Health Council propagates the idea of using individual patient data anonymously for collective purposes. The council refers to monitoring quality, business coordination, management support, research and statistics and education and policy. The record is expected to provide what is called ultimate strategic management information. Once such anonymous information at the collective level is available, it can be used to calculate norms against which individual patients can be measured. The relation between individual and population works both ways. Because of this, I would add the “subject of reciprocity” to the subject counter as a third way in which the care receiver can be shaped. [CLICK] The choice of technical infrastructure is important here. The idea of keeping the health record on a patient-held chip card was not favoured by the Public Health Council because it wouldn’t allow for generating population-level data.
A final point that is interesting in this respect is the question of resistance. This became increasingly important for Foucault throughout his life. All Dutch citizens are given the opportunity of opting out of the electronic health record infrastructure. However, the information package that they received about this in 2008 only concerned their individual involvement. Collective issues were not mentioned. This implies that patients implicitly step into a reciprocal relation with the collective if they decide not to opt out. We might wonder if more citizens would decide to refuse the use of their data if they knew about these macro-level objectives.
What is important to note in this respect, is that many of the expectations that underpin this policy seem rather unrealistic. Particularly Marc Berg, whom most of you know I suppose, has challenged the assumption that secondary use of these data is within reach. Even if it were possible, the costs of such an innovation are likely to outweigh its benefits. Also the assumption that the electronic health record would prohibit medical mistakes is often questioned. It is just as easy to have problems with digital data, as it is with sloppy handwriting. There is a lot more to say about the immoderate expectations of this discourse that I will need to omit. What does that mean for the subjectivity of the care recipient? Are the three types of subjects that I have indicated so far not realistic? Or should we add another category to the list, the “subject of immoderate expectations”, for instance? [CLICK]
This already shows that reality is rather complex. The creation of this infrastructure is not as straightforward as a Foucauldian analysis may suggest. The political discussion extends beyond policy-making. Those who create the technology for this infrastructure are just as important in shaping the politics that it will carry out. Part of this technology is the creation of technical standards that regulate the communication between different elements of the electronic health record. At the end of the 1990s, a so-called standards war emerged between two groups with strongly opposing ideas. For simplicity’s sake, I will refer to them as the European and the American approach, even though this is not entirely correct. To make matters more complicated, I identify two camps in both approaches. On the basis of this, I draw out four scenarios for the future infrastructure, rather than the one that I outlined before in my discussion of reciprocity. They may be summarised in a matrix, which you see here on the slide. First of all, the American side favours a fairly simple approach that merely standardises the referral message that would be sent from one care provider to another. Let’s say from a general practitioner to a specialist. The European approach, by contrast, proposes to standardise the health record as a whole. It standardises information, instead of communication. This is one axis. The other axis indicates whether the health record would be standardised to serve the patient, or to serve the health sector as a whole. This way, four scenarios appear, which I briefly discuss.
The virtual record, in the top-left quadrant, is mainly a tool for care providers. It does not do much more than to send electronic referral messages, with lab results for instance. The relations of the patient do not really change compared to the current situation.
The chain-integration record, to the right, is still part of the American approach. It also sends referral messages, but in a particular medical context, such as a chronic illness like diabetes. The proposal is to store all messages that relate to a particular patient in one record. A patient could have more of these records, for different medical conditions. This approach is mainly meant for so-called expert patients, people who often have more knowledge about their treatment than their doctors. This is important in terms of subjectivity. [CLICK] The “expert subject” is largely similar to the “principal subject”, but is confined to a minority of the entire patient-population.
The personal health record scenario is also patient-centred. The difference is that the European approach standardises medical information instead of referral messages. This implies that a patient would have a record in which all his or her health-related information would be stored in a standardised format. This goes beyond particular medical chains. Proponents of the European approach foresee that commercial products like Google Health and Microsoft Healthvault would adopt this standard as well. These applications are now already used for storing data about one’s physical condition, often in a gym, or while jogging. If the same standards are used, this health data could be stored in the health record as well. It would co-exist with the medical data that the doctor generates. It would no longer be a sickness record, but an actual personal health record. This again evokes a different conception of the patient, who is in fact no longer conceptualised as patient. Let’s call this category the “self-managed subject”. [CLICK]
I call the last scenario the public health record. It is this scenario that comes closest to the Foucauldian interpretation that I outlined before. The technical approach is very similar to the personal health record. What is added, however, is that all this standardised data can be anonymized for secondary use, by researchers, politicians, or managers for instance. In order not to make matters more complicated, let’s equate this type of patient with what I earlier called the “subject of reciprocity”.
Now, which of these scenarios is most likely to be selected? This is hard to say. The trend in technology is moving towards the European approach, so to the second row. At the same time, patient-centeredness is getting more and more important, which would point at the second column. However, if all information is standardised, won’t it be very appealing to use it for secondary purposes as well? This is hard to predict. Earlier this year, the Dutch senate criticised the electronic health record plans for these secondary purposes. So, maybe it will end up being more moderate than a Foucauldian interpretation would suggest? I don’t know.
So far, I have covered the first two ways in which Foucault discussed subjectivation, and two ways of thinking about innovation. The subject counter reads six. The last thing I discuss is what Foucault called self-constitution. When I started, I mentioned a number of practices that we can perform to shape ourselves. We could keep a diary of our daily achievements, force ourselves to contemplate on the day that is past before going to sleep, and we could discuss the goals we have in our lives with our closest friends. Foucault discusses ways in which these practices are institutionalised. In antiquity, he found a culture that was entirely oriented to these ways of self-development. There were communities that people joined for this purpose, and mentors that could supervise your developments. He was also interested in the practice of Zen, for instance, which is somewhat similar. Even though Foucault would not suggest that we can just adopt the model of antiquity in our times, he did argue we can take learning of some aspects of this culture.
Different healthcare scholars have started looking for contemporary examples of practices to work on the self. The most interesting example is a study by Cressida Heyes of her experiences with the weight watchers, a popular organisation that facilitates dieting. She notes the same types of institutional support as Foucault highlighted. There are weight diaries, group meetings and dieting mentors. The most interesting part of her study is that she situates her attempts to shape herself in relation to several dominant discourses. On the one hand, there is the societal pressure of being slim and good looking. On the other hand, there is the pressure of feminism that tells women not to subjugate themselves to societal expectations. In a very personal way, she shows how self-constitution is always compromised by broader power relations.
What does this have to do with technology and innovation, you may wonder? Well, my argument is that technology can also be regarded as an institutional setup in which self-constitution can take place. Electronic health record applications, for instance, often contain the option of keeping an online health diary, which can be shared with a doctor. This comes quite close to what I described earlier as the “self-managed subject”. However, if it is motivated by a purposeful attempt to do self-development, let’s add a new category to be complete. [CLICK]
With respect to technology and self-constitution, online chat rooms for particular medical conditions are probably the most interesting example. They contain all elements that Foucault described: communities, mentoring, and practices like critical reading and writing. In studies of such chat rooms, the same feeling of compromised self-development that Cresside Heyes described appears. Many patients go to such website to escape the medical context that they often experience as oppressing. Also geographical boundaries are defied. Nevertheless, medical experts have been reported to invade such communities, to the dislike of these patients. At the same time, the writing that is perceived as empowering is also visible to the entire world, which is occasionally abused. I believe that this is exactly what Foucault aimed at: the idea that we try to work on ourselves as much as we can, with the awareness that we can never do so entirely. Maybe you will allow me to add a last category to our subject counter? I guess I will call it the “subject of compromised self-constitution”. [CLICK]
