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Journal of Medical Humanities, Vol. 24, Nos. 3/4, Winter 2003 (°

C 2003)

Governmentality, Critical Scholarship,

and the Medical Humanities
Alan Petersen1

Foucault’s work has had a profound impact on the medical humanities over the
last decade or so. However, most work to date has focused on Foucault’s earlier
writings rather than his later contributions on the self and governmentality. This
article assesses the significance of the concept of governmentality for critical
scholarship in the medical humanities, particularly in creating ethical awareness
in the field of health care. It examines the context for Foucault’s later work, and
contributions arising from scholarship building on this work. The governmentality
literature, it is argued, raises novel questions about the ways we have come to think
about health care in late modern societies. However, there are some limitations
with this body of work which have not been fully acknowledged by scholars. The
article discusses some of these limitations and offers some suggestions for a fruitful
way forward.
KEY WORDS: Foucault; governmentality; critical scholarship; medical humanities; health care;
ethical awareness.

The uptake of Foucault’s ideas by scholars in the medical humanities over

the last decade has been astounding. Foucault has exercised a profound influence
on thinking about the objects of study and methods of analysis, leaving forever in
question the assumed separation of the natural and the social. Much scholarship
in the medical humanities has been inspired by Foucault’s early work on modes of
regulation associated with the shift from sovereign power to disciplinary power,
and the emergence of biopolitics in the eighteenth century (Foucault, 1977, 1980).
Foucault’s insight that modern power is not simply a negative or repressive force
but a positive or productive force has led to innovative work in a number of domains
of health care practice; for example, analyses of body regulation, the constitution
1 Address correspondence to Alan Petersen, Department of Sociology, University of Plymouth, Drake
Circus, Plymouth PL4 8AA, UK; e-mail: a.petersen@plymouth.ac.uk.

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of the patient/client, the power relations of doctor-patient communications, and

the constitutive and regulatory power of medical technologies (e.g., Armstrong,
1983; Nettleton, 1992; Sawicki, 1991; Silverman, 1987). (For a recent account of
Foucault’s contribution to medical sociology, see Turner, 1997). In comparison,
Foucault’s later contributions of the self and on governmentality have received
much less attention. This is surprising, since this work forces us to rethink certain
aspects of Foucault’s earlier work and has important implications for the critical
analysis of the policies and practices of health care. This article assesses the sig-
nificance of the concept of governmentality for critical scholarship in the medical
humanities, particularly in creating ethical awareness in health care.
In recent years, governmentality scholars have produced a substantial body
of literature concerned with contemporary practices of governing with a focus
on the active subject as the entity through which, and by means of which, power
is exercised. These scholars have developed a powerful repertoire of conceptual
tools in their efforts to explicate the modes of rule associated with the shift from
“welfarist” to neoliberal politics. At a time when scholars and activists are try-
ing to come to grips with profound changes in modes of health care delivery, the
governmenality literature offers a powerful framework for analysing and evalu-
ating the strategies and practices of health care. Governmentality studies focus
attention on the conduct of conduct: how we conduct ourselves, how we attempt
to conduct others, and how others attempt to control our conduct. As such, these
studies can play an important role in helping to render visible the ethical con-
tent of the particular practices of self associated with contemporary forms of
rule.
The article begins by examining Foucault’s later work on the self, which inter-
sects with and informs his own and his followers’ thinking about governmentality
as it applies to the analysis of rule in contemporary societies. It then moves on to
examine the aims and applications of governmentality scholarship and the context
within which this work arises, pointing to its relevance to the analysis of con-
temporary practices of health care. There has been a tendency among Foucauldian
scholars to view Foucault’s writings on the self and on governmentality as discrete,
unrelated projects. However, both projects were developed during the same period
of his life and reflect Foucault’s growing concerns with processes of self-subjection
or self-governance, particularly as they manifest in societies characterised by lib-
eral and neoliberal forms rule, and with exploring the possibilities of developing
alternative practices of the self. The relevance of Foucault’s concept of govern-
mentality in particular, although developed to only a rudimentary level in his own
work, could provide the foundation for the renewal of the medical humanities
and serve to link scholarship in this field of study more directly with radical pol-
itics. However, as I will argue, some limitations with existing governmentality
work first needs to be acknowledged and some shift in research focus needs to
occur.
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Governmentality, Critical Scholarship, and the Medical Humanities 189

FOUCAULT’S PRACTICES OF SELF

Towards the end of his life, Foucault recognised that most of his own efforts
had been focused on the technologies of domination and power to the neglect of
the technologies or practices of the self. He believed that this was a serious omis-
sion in his work since, in modern society, the conduct of individuals is regulated
not so much through overt repression or coercion but rather through subjects’
active engagement with recommended or imposed practices which served to nor-
malise behaviour. In his final writings, Foucault turned his attention to the ethical
practices of the ancient Greeks and Romans for what could be learned about the
possibilities for subjects reinventing themselves in ways that break with the nor-
malising discourses of modernity (Foucault, 1987, 1990). He believed that the idea
of morality as obedience to a code of rules was undergoing a decline as part of a
general scepticism towards the grand narratives of religion and politics and that
this created the space for the development of a greater degree of autonomous self-
stylisation. The ancient Greeks, Foucault suggested, provide an example of the
kind of autonomous existence that might be possible (see Kritzman, 1988, pp. 49,
249, 253–254). In modern society, the technologies of power are hidden by the
screen of individualisation, which involves an endless examination of one’s inner
self. This is seen, for instance, in the use of psychoanalysis to “discover” the truth
of our sexuality (see Foucault, 1980). Foucault saw the exploration of the self not
as a liberation of a true or essential inner nature, but rather as an obligation that the
individual faced to constantly reinvent him or herself. In his view, ancient Greek
ethics were free of the normalising pressures evident in contemporary societies
and thus provided a kind of model of how to develop a new ethics of the self.
For the Greeks, in order to practice freedom properly, one needed to care for the
self, both in order to know oneself and to improve oneself. Being free meant not
being a slave to one’s self and to one’s appetites, and this presupposes that one
establishes over one’s self a certain relation of domination, or mastery. This stands
in contrast to the contemporary concept of care for the self, which is equated with
a kind of self-love, egoism or self interest (Bernauer & Rasmussen, 1991, pp. 4–6).
Contrary to some interpretations, Foucault’s interest in ethical practices of the self
in his final work did not represent the abandonment of a concern with politics.
Rather, as Bernauer explains, he conceived the politics of ourselves as a crucial
political issue and was interested in exploring the “form of becoming a subject that
would provide an effective resistance to a specific and widespread type of power”
(Bernauer, 1991, p. 51).
As is widely recognised, Foucault’s thinking about power and subjectivity
was a response to the dominant, Marxist conception of power as centralised in
the state. In Foucault’s view, the state does not have the unity, functionality, or
importance widely attributed to it: rather, the institution of the state is a function
of changes in practices of government. It is for this reason that Foucault spoke
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190 Petersen

of the governmentalization of the state (Foucault, 1991, p.103). Although he did

not deny the power of the state, he saw the modern form of government as dis-
persed through a multitude of locales and authorities, in a capillary fashion, such
that there was no escaping power relations. In his view, relations of power were
always present in all human relations, in verbal communication, in intimate re-
lations, and in institutional and economic relations. The political task, then, was
not to create a society without relations of power, which was a utopian dream,
but rather to create the “rules of law, the techniques of management, and also the
ethics, the ethos, the practice of self, which would allow these games of power to be
played with a minimum of domination” (Foucault, 1991, p. 18). In Foucault’s view,
practices of the self are not invented by subjects themselves but rather are “pro-
posed, suggested and imposed” on them by one’s culture, society and social group
(1991, p. 11).
As Garland argues, the use of the term freedom (as in practices of freedom)
by Foucault, and subsequently by many of his followers, is highly misleading
and would be best replaced by agency, which acknowledges capacity of an agent
for action—its possession of the power to act—without assuming unconstrained
choice (1997, pp. 196–197). Foucault believed in the possibility of people using
their agency to effect change in the relations of power. As he stated on a number
of occasions, where there is power there is necessarily the possibility of resistance
(see, e.g., Foucault, 1991, p.12; Foucault, 1980, p, 95). Indeed, the individual’s
ability to resist power occurred through the very techniques by which he or she is
governed (McNay, 1992, p. 68). As he pointed out in an interview, power relations
are “changeable, reversible and unstable,” a consequence of the fact that power re-
lations are contingent upon the existence of “free” subjects (Foucault, 1991, p.12).
Unfortunately, Foucault never elaborated on the mechanisms by which subjects
might effectively contest and change the relations of power. However, his work on
governmental rationality or governmentality can be seen to have paved the way
for a detailed exploration of these mechanisms.

ENTER FOUCAULT’S GOVERNMENTALITY

Foucault’s lectures on governmentality signal the beginning of an effort to

make explicit and explore the interface between technologies of domination (the
focus of his early work) and the technologies or practices of the self introduced in
his final volumes of the History of Sexuality (see Foucault, 1991). The steps which
brought Foucault to his analysis of governmentality and the foci of his work in
this area have been outlined by Gordon in his introduction to The Foucault Effect
(Gordon, 1991). As Gordon explains, Foucault defined government in general as
meaning “the conduct of conduct”: that is, the forms of activity that aim to “shape,
guide or affect the conduct of some person or persons” (1991, p. 2). Foucault was
interested in government as an activity or practice and a way or system of thinking
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Governmentality, Critical Scholarship, and the Medical Humanities 191

about the nature of the practice of government. It concerns questions such as who
can govern, the content of governance, and who and what can be governed (1991,
p. 3). Government is productive in the sense of making some form of activity
thinkable and amenable to action by both practitioners and those upon whom it
was practiced. It is important to recognise that governmentality does not refer to
a theory of governance but rather to an analytics of power that focuses on the
mentalities or rationalities of government as they operate in particular domains
of social life. In respect to this analytics, there is no consensus about a “correct”
methodology and no general thesis, as one might find in other areas of social
science scholarship. Hence, governmentality scholarship is perhaps best described
a “zone of research” rather than as a fully formed product or thesis (see Gordon,
1991, p. 2).
One of the foci of Foucault’s work on governmentality was the development
of liberal and then neoliberal thought considered not as political philosophies but as
ways of thinking or rethinking the rationality of governing. It is this line of analysis
of government that has been developed most fully by governmentality scholars in
recent years (e.g., Barry, Osborne, & Rose, 1996; Burchell, Gordon, & Miller,
1991; O’Malley, 1996a; Rose, 1993, 1996, 1999; Rose & Miller, 1992; Valverde,
1996). Employing the medical metaphor of diagnosis to describe their analytic task,
governmentality scholars have sought to plot “the historically contingent limits of
present thought and action” (Burchell, 1993). As Nikolas Rose, one of the most
prolific governmentality scholars, explains, studies focusing on the analytics of
government are concerned with bringing certain questions into focus:
These studies [of governmentality] do not seek to describe a field of institutions, of struc-
tures, of functional patterns or whatever. They try to diagnose an array of lines of thought, of
will, of invention, of programmes and failures, of acts and counter-acts. Far from unifying
all under a general theory of government, studies undertaken from this perspective draw at-
tention to heterogeneity of authorities that have sought to govern conduct, the heterogeneity
of strategies, devices, ends sought, and conflicts between them, and the ways in which our
present has been shaped by such conflicts. (1999, p. 21)

In his book, Powers of Freedom: Reframing Political Thought (1999), Rose

outlines a number of recent changes that make many of the conventional ways of
analysing politics and power seem obsolescent and that necessitate a new style of
analysis. As he explains, many of our ways of thinking about politics and power
are a product of nineteenth century thought when political systems seemed to be
defined and to be limited by the nation-state. Within philosophical and constitu-
tional thought, power was imagined as a centralised body within any nation, a
collective actor with a monopoly of the legitimate use of force within its defined
territory. These styles of thinking about political power also embodied a concep-
tion of human beings as subjects of power, who were autonomous, bearers of
rights, and possessors of will and agency. Human collectivities, too, tended to be
seen as singularities which provided the basis for political interests and actions:
classes, races, interest groups. Within this schema, freedom was imagined as the
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192 Petersen

absence of coercion or domination, that is, in negative terms. As Rose argues, “it
was a condition in which the essential subjective will of an individual, a group or
a people could express itself and was not silenced, subordinated or enslaved by an
alien power” (1999, p. 1).
As Rose observes, increasingly, these images and vocabularies are being
challenged by politics itself: globalisation and demise of the nation-state and the
rise of new political couplings and alliances. These developments have brought
into question conventional notions of the relations between the state and citizens
and the sources of political legitimacy and citizenship. A new ethical politics
has emerged, focusing on the environment, health, reproduction, animal rights,
of everyday life itself, and rejecting the notion that politics is a matter of the
state, parliament, election and party programme. We have seen the rise of anti-
political themes, that cannot be readily contained by traditional left-wing and
right-wing political ideologies, with widespread claims about the failings of the
state provision of welfare, crime control, education, etc., and demands that the
power that has been acquired by the state be returned to individuals, families,
communities, and employers. It is in the light of such events, argues Rose, that it
is relevant to consider whether these images adequately capture, or indeed have
ever captured, the strategies and techniques by which individuals and populations
have been governed in the West since the late eighteenth century (1999, p. 2–3).
In recognition of the limits of present ways of thinking about politics and
power, Rose and other governmentality scholars have explored the operations of
power beyond the state, with a particular focus on the contemporary phenomenon
of neoliberalism. This work has been insightful and interesting, serving to cast
new light on old problems and generating novel lines of analysis; for example,
the governance of pregnancy (Weir, 1996), the technologies of risk (O’Malley,
1996b), the policing of sexual violence (Carrington & Watson, 1996), the regula-
tion of people living with AIDS (Kinsman, 1996), the production of “harm min-
imisation” and the government of “drug users” (O’Malley, 1998), and processes
of self-subjectification associated with the self-esteem movement (Cruikshank,
1996). Underlying this work is the recognition that there is no single logic of rule:
the techniques and technologies of rule are various and differentiated and operate
largely beyond the state. Furthermore, within studies, individuals are conceived not
as coerced objects or ideological dupes, but as agents whose subjectivity is formed
through active engagement with the powers that govern them and through which
they govern themselves (Garland, 1997, p.183). These writers have focused on the
shift from welfarism to neoliberal governance, giving rise to new policies empha-
sising entrepreneurial, consumerist culture and governance through freedom. As
Rose argues, the significance of society as an object of analysis has begun to lose
its self-evidence, and we have begun to see the emergence of a range of rational-
ities and techniques that seek to govern not through governing society but rather
through the regulated choices made by discrete and autonomous actors (Rose,
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Governmentality, Critical Scholarship, and the Medical Humanities 193

1996). In line with this, professional expertise has begun to take on a new role at
a distance, outside the institutions of bureaucracy that previously linked expertise
to technologies of government. Increasingly, the notion of empowerment and the
techniques of risk have come to play a crucial role as techniques and technologies
of governance, in shaping the conduct of individuals in ways which make them
more self-governing (1996, p. 348–350).

GOVERNMENTALITY AND THE CHANGING CONTEXT

OF HEALTH CARE

The potential relevance of the concept of governmentality to those working

in the medical humanities may not be immediately evident to those unfamiliar
with the premises underlying this field of study. Unlike most other fields of study,
governmentality work does not offer a ready made set of hypotheses or theories
that can be applied to an existing set of issues or problems. As mentioned, it is
best described as being a zone of research rather than as a fully developed thesis.
For this reason, many writers prefer to speak of “the governmentality literature”
or “governmentality studies,” rather than of, say, “governmentality theory” or “the
governmentality school.” Governmentality scholars have offered a useful reper-
toire of tools for analysing the mentalities or rationalities of rule and the ways of
thinking and acting that they entail, rather than proposing a new, all-encompassing
theory of government. This sets it apart from those sociological and historical
approaches that are concerned with revealing some hidden “truth” about “what ac-
tually happened” or what government is really about (O’Malley, Weir, & Shearing,
1997, p. 502).
The governmentality literature raises novel questions about the ways we have
come to think about health care in late modern societies: as an arena for study
and action and as a set of presumed practices of the self. In a context of reduced
government spending on health care, privatisation of services, the operation of new
systems of accountability and cost-effectiveness, and efforts to make individuals
and communities more self-reliant and self-determining, scholars urgently need
new tools of analysis. Scholars need to rethink the concepts of power and politics
if they are to formulate an effective response to the unjust and dehumanising
aspects of neoliberal policies and practices that have come to dominate many
contemporary health care systems and to create greater ethical awareness in health
care. In particular, they need to recognise the increasing reliance on technologies
of self-governance, as they operate in the multiple sites and agencies outside the
bureaucracies of the state—in the workplace, in the community, in our homes, and
in our personal relations. More and more, in the health care arena, the concept of
the active consumer, has come to replace the notion of the passive patient. The
subject has been accorded new obligations and a new set of relationships with
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194 Petersen

experts on whom they have come to depend for guidance and advice. A change
in the relationship between the state and citizens is reflected in the recent shift in
welfare philosophy from entitlement to mutual obligation. While agencies of the
state continue to play an important role in the provision, coordination and funding
of many health care and welfare services, more and more citizenship “rights” to
services are circumscribed by specified “duties.” The notion that individuals have
a right or a reasonable entitlement to government-protected minimum standards in
health, housing, education and social security has been displaced in a number of
contemporary societies (e.g., Britain, the United States, and Australia) by the idea
that individuals have an obligation to make some contribution to the community
as a precondition of membership of that community (Macintyre, 1999). Care of
the self has become equated with “self-reliance,” with “freedom” from “welfare
dependency,” and with earning the support and protection that was previously seen
as an obligation of the state. Often, in practice, this has meant the denial of access
to services or benefits than were previously seen as a right (e.g., unemployment
or disability benefits), higher levels of poverty in the population, and a greater
expectation that women will shoulder the burden of care (of children, the aged,
the sick, and the disabled).
The changing relationship between citizens and the state is mirrored in the
newly-emergent notion of the stakeholder society, which stresses the stake that
all should have in the economic and political institutions of a community and the
necessity for basing planning and policy on the positive basis of inclusion and
ownership rather than the negative ones of conflict and exclusion. As Macintyre
explains, the stakeholder society employs the language of company shareholders
and reworks Locke’s notion of the social contract so that, instead of the privileging
of the individual ahead of the state, there is more or less equal weight between the
individual and the agencies of the state. Like individual shareholders in a company
who are expected to make some contribution in order to have some voice in the
running of the company, individual citizens must make some contribution if they
are to be part of the agencies of economic, social and political planning (Macintyre,
1999, p. 114). The notion of the stakeholder society is reflected in contemporary
health care philosophy: citizens are increasingly expected, as a condition of access
to health care services, to play their role in minimising their contribution to health
care costs by becoming more responsible health care “consumers,” and adopting
appropriate practices of prevention. These expectations are enacted in a multitude
of sites and are reinforced through new programs and institutional arrangements
(new modes of health care delivery such as health maintenance organisations in-
cluding an emphasis on community-based strategies, such as home-care, incentives
for self management of risk (rebates for taking out private health insurance and
premium penalties for “unhealthy” lifestyles), and the forging of links between dif-
ferent levels and areas of government, voluntary, economic and community groups
(e.g., “healthy public” policies) (Petersen & Lupton, 1996, pp.17–18, 137–138).
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Governmentality, Critical Scholarship, and the Medical Humanities 195

These diverse mechanisms reflect and reinforce a conception of the individual as

an enterprise who is entrepreneurial in outlook and ever vigilant of risks, opportu-
nities, and costs. The individual as health care consumer is viewed as an abstract,
rational decision-maker who is unencumbered by her social location and the con-
straints posed by relations of power and by one’s particular complement of skills,
resources, and personal and family commitments.
It is important not to lose sight of the productive potential of the imperatives
surrounding healthy citizenship and selfhood. Policies and practices assume, and
are addressed to, particular categories of people and presume quite specific modes
of action that did not previously exist. As Hacking (1986) reminds us, our descrip-
tions of human categories are inextricably linked with categories of human action:
“making up” people in new ways creates a new range of new possibilities for ac-
tion. The neoliberal strategy is to compel actors to express their agency in line with
official goals and to subject actors to penalties for error or for failure to comply.
Individuals are compelled to choose among an array of options, which present
constrained possibilities for action. Increasingly, the emphasis in health care is on
individuals’ “right to know” about risks to health and about the possibilities for
prevention, care, treatment, etc., and the “right to choose” among the available
(i.e., predetermined) options. However, there has been little discussion about the
individual’s right not to know and the right not to choose, since this would run
counter to the imperative to be an active decision-maker and would throw into
question the legitimacy of the compulsory structures which compel an agent to
behave in particular ways. Those who seek to operate outside predetermined lines
of action risk being labelled irresponsible or as troublemakers and suffering finan-
cial penalty of some kind or being denied access to services or advice. In other
words, the range of possible ethical actions is always circumscribed (although not
determined) by the imperatives of rule.
The operation of these new strategies of rule and the ethical imperatives to
which they give rise, can be seen clearly in the areas of prenatal genetic screening
and genetic counselling, which have become increasingly central components of
the technologies of preventive medicine in recent years. The “new” genetic-based
preventive medicine is seen to differ from the “old” eugenics by its emphasis on
individual empowerment through the creation of individual choice. Whereas eu-
genics is seen as top-down, coercive control exercised by the state, one of the
promises of the new genetics is seen as opening a range of new possibilities for
choice and action. A major underlying assumption of genetic screening, which
is clearly articulated in health promotion literature and policy documents, is that
individuals have a right to know about their genetic health and that of their future
offspring. Access to such knowledge is seen as integral to the promotion of indi-
vidual autonomy (Petersen, 1998). Genetic screening allows genetic counsellors
to calculate the individual’s or couple’s genetic risk, which then presents certain
options for individual action. In prenatal diagnosis, such information is viewed
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196 Petersen

increasingly as crucial to prospective parents’ informed prenatal decision-making.

According to genetic counsellors’ statements about genetic counselling practice,
articulated in the professional literature, genetic information should be given in
a nondirective manner, allowing individuals to come to their own informed deci-
sions. Nondirectiveness implies self-determination; an ability to make decisions
unencumbered by constraints of context, social location, and the power relations
between the counsellor and counsellor. Despite many counsellors’ recognition of
the limits of nondirectiveness, in practice nondirectiveness continues to be pro-
moted by the counselling profession as an ideal, thus reinforcing the view that the
counsellor is ethically neutral and that the counsellee is an ethically autonomous,
rational, self-directed actor (Petersen, 1999).
The point that remains unarticulated in debates about the personal benefits
of prenatal genetic screening is that new technologies of genetic screening and
related practices of genetic counselling compel individuals to become more ac-
tive decision-makers. As the use of new technologies of screening become more
readily available in the market and their use more routine in clinical practice, a
decision not to utilise such information is seen increasingly as irresponsible, if not
reckless, and as transgressing the rights of the unborn. The development of a new
technology carries the strong expectation that that technology will be applied. Prac-
titioners feel compelled to use the technologies in the effort to achieve certainty in
medical decision-making and as protection against litigation for “wrongful” births
(Shapira, 1998). On the other hand, individuals are expected to want to use these
technologies in order to make “responsible” decisions. Indeed, the development
and use of prenatal genetic technologies (and, indeed, other medical technologies)
is seen as driven by consumer demand. As practitioners themselves have come
to recognise, nondirective genetic counselling is at odds with the broader policy
goal of prevention, which is to reduced health care costs associated with treating
genetic-based illness and disability (e.g., Clarke, 1991). In the absence of genetic
therapies that will allow the correction of the genetic “defect” in the affected em-
bryo, the only real options available to parents at present are to continue with the
pregnancy or to abort. In other words, the development of technologies of prenatal
genetic screening creates choices but only within a predetermined range of pos-
sibilities. While it is true that prenatal genetic screening has generated new and
different options, some of which may be judged by users as beneficial, it should
not be assumed that individuals are therefore made to be “free.”
The case of prenatal genetic screening and genetic counselling illustrates
well how the compulsions of choice interact with broader imperatives surrounding
healthy living and responsible citizenship to reinforce and reward particular prac-
tices of the self. However, although the available options for action in health care
are often predetermined rather than “invented” by consumers themselves, there
is nothing inevitable about how individuals may act. Indeed, there is a great deal
of evidence that suggested or imposed regimes of health care such as prenatal
genetic screening and genetic counselling often fail to achieve what they set out
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Governmentality, Critical Scholarship, and the Medical Humanities 197

to do and may lead to unintended outcomes. Individuals creatively engage with

expertise, taking from encounters what they wish and interpreting information
within their own lay frameworks of knowledge, according to the perceived rele-
vance of information. In relation to the conveying of risk information, for example,
it is well known that there is a frequent mismatch between expert calculations of
risk (generally presented in terms of gaming odds) and “lay epidemiology” (see
Davison, Smith, & Frankel, 1991). Expert recommendations are frequently ig-
nored or contested by subjects when these do not accord with personal goals or
sociocultural assumptions and values. For example, efforts to include women in
genetic screening for sickle cell disease in the United States met the resistance of
women whom they were intended to serve since they did not take account of the
cultural significance of motherhood in their communities (Hill, 1994).

Limitations of Governmentality Studies

Unfortunately, despite abundant evidence that governmental programmes fre-

quently fail or are only imperfectly realised, governmentality scholars continue to
privilege official discourses in their studies and to overlook the messy actualities of
social relations (O’Malley, et al.,1997, p. 509). The tendency of scholars to focus
selectively on abstract rationalities of rule and to neglect noninstrumental rational-
ities leaves the impression that governance is perfected and fully formed and limits
the potential of governmentality studies to contribute to radical politics (Garland,
1997, pp. 198–202; O’Malley, et al., 1997, pp. 508–512). As a number of writers
have argued, governmentality scholars have paid inadequate attention to the study
of counterdiscourses, contestations, and resistances or to see these only as sources
of programmatic failure. This neglect leaves scholars open to the charge of rein-
forcing a top-down, state-centred view of government (Garland, 1997; O’Malley,
1996a; O’Malley, et al., 1997; Kerr, et al., 1999; Stenson, 1998). As Garland ex-
plains, although writers such as Rose (1996a) and Gordon (1991) have stressed
that government programmes are never perfectly realised in practice, this warning
is frequently ignored because of a bias in this kind of scholarship which uses the
evidence of historical documents to identify and reconstruct systems of thought or
ways of knowing. This bias can be traced to Foucault’s early concerns with sys-
tems of thought and with uncovering and differentiating epistemes (Garland,1997).
Thus, despite abundant evidence that contestations, resistances and social antago-
nisms shape rule through the implementation of alternatives, the rationalities and
technologies are portrayed as abstract and all-dominating. As Garland argues, it
makes little sense to analyse abstracted rationalities without proceeding to analyse
how they actually function in practice (1997, p. 200).
Given this evident bias in the literature, a number of writers have recently
called for governmentality scholarship to (re)connect with critical theorising in or-
der to make it politically relevant (Garland, 1997; O’Malley, et al., 1997; Stenson,
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198 Petersen

1998). In neglecting social relations in their analysis of the political, particularly

the exclusion of contestation and diversity among the governed, governmental-
ity scholars have limited their potential to contribute to change. As O’Malley
et al. point out, if governmentality literature is not to degenerate into “ritualized
and repetitive accounts of ‘governing’ in increasingly diverse contexts,” it is im-
portant that there be more open and vigorous debate about core issues such as
the role of critique, the relevance of the diagnostic model in the analysis of gover-
nance, and the significance of contestation and resistance as foci of analyses (1997,
p. 514).
Stenson (1998), too, sees the need for more radical critique within studies
of governmentality. Although he recognises that governmentality theorists have a
major role to play in identifying the rich complexity and hybridity of modes of
governance and in helping to reformulate programmes and technologies of liberal
government at local, national and international levels, the tendency to distance
critique from liberalism has restricted governmentality scholars’ role as public
intellectuals. Governmentality scholars have neglected to acknowledge that strate-
gies and practices initiated from “below,” for example, by indigenous peoples, are
themselves constitutive rather than being merely resistant or adaptive to govern-
mental programmes in state or professional agencies. (On this point, O’Malley
[1996a] has much to say.) In Stenson’s view, liberalism could become the focus
of a normatively committed form of governmentality studies which could, in turn,
emerge as its principle vehicle for critique and renewal. This requires that schol-
ars expand their methodological repertoire beyond the history of the present and
a focus on the mentalities or rationalities of rule. There is a need to acknowl-
edge the messiness of human practices, and the importance of dissent that has
been facilitated by and has been, to a degree, constitutive of liberalism (1998,
pp. 347–350).

A Way Forward

If governmentality work is to contribute to critical scholarship, scholars need

to recognise the ways in which subjects, individually and collectively, tactically
deploy the practices and products imposed on them to achieve particular ends (see
de Certeau, 1984). The study of the suggested or imposed rules of conduct needs
to be complemented by the study of ways in which subjects use, manipulate, and
transform the contexts in which they find themselves. In the contemporary context
of neoliberal governance, it is important that scholars acknowledge how particular
strategies of rule create new avenues for action and new claims to citizenship rights
based upon concepts such as “consumer,” “empowerment” and “participation.” In
respect to health care services, citizens have made strategic use of their status
as members of identifiable consumer communities to demand collectively access
to better, or more appropriate, services. Through the deployment of essentialist
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Governmentality, Critical Scholarship, and the Medical Humanities 199

categories of identity (e.g., “women,” “indigenous peoples,” “the disabled,” “the

aged”), consumer communities have been able to extract concessions from au-
thorities, to broaden access to existing health care services, and to force change
in health-related policies and practices. By making liberal use of the rhetorics of
empowerment and protective mechanisms already enshrined in law (e.g., Citizen’s
Charters, antidiscrimination legislation), minority and disadvantaged groups have
been able to derive benefits and develop novel approaches and practices within the
existing social arrangements. Thus, although constrained by imposed procedures
of accountability and cost-effectiveness (e.g., performance indicators), these di-
verse communities have been able to utilise selectively expertise and services and
to access financial and other resources to develop, in a relatively autonomous (i.e.,
self-directed) way, a range of services that are more appropriate to their respective
communities. The women’s health movement represents a particularly successful
challenge to the institutional power of health care professionals and the authority
of professional power and practice and has acted as a catalyst to other self-help
and health promotion groups in the health care field (Broom, 1991; Irvine, 1996,
p. 205). The health consumer movement has been able to shape institutional poli-
cies in the face of strong opposition from professional organisations. For example,
in Australia, the health consumers’ movement has played an important role in the
establishment of formal channels at the State level through which the public can
complain about quality of care and unsatisfactory practice (Irvine, 1996, p. 206).
As part of the effort to (re)connect with radical politics, governmentality
scholars need to forge a more fruitful dialogue with other kinds of social science,
particularly sociological enquiry. In the past, governmentality scholars’ rejection
of systematic generalisation and theory-building has reinforced the tendency for
governmentality scholars to sharply differentiate their work from, and to overlook
the contributions of, other forms of sociological analysis (Garland, 1997, pp. 204–
205). Although the assumptions, methods and analytic claims of governmentality
work are strongly at odds with some strands of social science—most notably state-
centred Marxist theory—as Garland notes, there is no necessary incompatibility
between governmentality studies and other social science work (1997, p. 205).
The emergence of a body of governmentality scholarship does not render obsolete
previous social science work but rather raises a new, distinctive array of questions
for scholars to consider. Governmentality scholars’ engagement with the work of
other scholars is likely to lead to a reappraisal of existing approaches and of pre-
vious findings. For example, in the field of the sociology of health promotion, the
governmentality literature raises questions about the resistive potential of “non-
compliant” behaviour, previously seen as irrational and irresponsible and in need
of explanation and control (Hughes, 1997). With its emphasis on the how of ruling
and its bracketing of traditional theory questions about the causes and functions
of ways of ruling, governmentality analysis holds great promise in bypassing the
unfruitful division of labour between social researchers’ descriptions of how and
theoreticians explanations of why (Valverde, 1996, p. 358).
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200 Petersen

As Garland explains, many sociologists (and the argument can be extended

to other social scientists) would have little trouble accepting the central claims of
governmentality scholars: the dispersion of power throughout society as well as
its concentration in the state; the premise that power operates through networks
of action that traverse the legal-constitutional divisions that supposedly separate
the state from civil society; and the rejection of the unified, totalised conception
of society in favour of a more pluralist account of social relations and institutions.
Despite the tendency to distinguish governmentality work from other forms of
scholarship, there is no reason why there cannot be a more fruitful dialogue between
the different forms of work (1997, p. 205). In raising the kinds of questions that they
do—about the rationalities of rule and about the ways in which we are made and
make ourselves into subjects—governmentality studies can usefully complement,
challenge, and enrich other work in the medical humanities. The creation of a
dialogue between governmentality scholars and other scholars would seem to be
crucial if one is to properly assess the possibilities for developing more ethical
practices in health care in a period of rapid and profound change.

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