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One fundament. One firework. Plant it and retreat. Sadly, the result seems to have been barely a fizzle. Roger Cooter tried to provoke a debate in these pages about how ‘medico-centric historians’ should engage with what he sees as the fundamentally ‘bio-centric’ contemporary world.1 Well, I for one feel like I've had a firework stuck up the centre of my bio-existence, and I intend to return the favour. In truth, I have a lot of respect for Roger Cooter and his work. But there are fundamental issues in his article that I think need bringing into relief. They are important and need arguing about.
Let me begin by agreeing with Cooter's general statement about important elements of the contemporary world:
…the reconfiguration of rights and citizenship, the withdrawal of the state from health and welfare, the creation of commercial spaces beyond academic bioethics, and the roles of philanthropy and the media in contemporary health and health education, demand not just new ways of thinking about the present and the future, but also, how the practice of historicising might be re-thought.2
My problem is with his proposal for how ‘we’ should go about this. On my reading, Cooter's article covers four substantive issues. First, he historicises, and criticises, the history of medicine discipline. Second, he highlights Michel Foucault's work as crucial to appreciating why the discipline is ill-prepared for the political and intellectual issues that should concern us in the present. Third, he uses this critique as justification for proposing that a Foucauldian-inspired approach be adopted by medical historians. Fourth, he uses this, in turn, to argue that historians of medicine can renew their remit by turning away from their ‘traditional’ discipline and its concerns, to focus instead on the biosciences and biopolitics. There is good reason to pay more attention to the biosciences and biopolitics. But what I want to concentrate on here is the way in which Cooter thinks that this should be done, and his dismissal of any other foci for ‘medico-centric historians’.
Though he proposes a ‘re-radicalisation’ of historical work, Cooter, in fact, begins from the traditional perspective of the historian. He states that ‘never before has the need been greater to understand where we've come from as a means to obtaining a better purchase on the place where we've arrived’.3 He looks to the career of the social history of medicine since the 1970s, and elaborates the conceptual flaws that he believes have ultimately led to its lack of capacity for serious intellectual and political engagement.
First of all, we should note that, in his dismissal of the relevance of the social history of medicine, he lumps together both early examples of the discipline that emerged via economic history, and social constructionist approaches that emerged later. He describes them as united by a pretty straightforward notion of oppressors and oppressed; top-down power and bottom-up resistance; medical agents on the one hand, and the ‘pathologised and medicalised on the other (especially women, the working class and the mad)’.4
In part, I agree with him. Some work in the social history of medicine partook of a black and white division of ‘bad’ doctors and ‘good’ patients, or the medical wielding of power as necessarily ‘bad’ and resistance to it as necessarily ‘good’. Cooter uses this as a reason to dismiss this past; I don't. In truth, it would be a bit of a travesty to reduce the past of the social history of medicine to that. Where I have criticisms, they focus mainly on the paternalism inherent in a lot of the social history of medicine. For example, one issue with the ‘top down power and bottom up resistance’ approach that Cooter highlights is that so much of the social history of medicine decided who ‘the oppressed’ were and then spoke for them. While it did help open up and expose imbalances of power, the social history of medicine often did not notice or engage with imbalances of power that emanated from its own practice and institutional position. Cooter ignores this aspect, but despite that, there are many difficult issues here that are still very much worth engaging with. My criticisms, unlike Cooter's, do not amount to a dismissal. I am not saying that the history of medicine was (and still is in many ways) paternalist—and there is an end of it. On the contrary, I am saying that this was, is, and likely always will be, an ever-present issue that it is essential to try to engage with, even if it might never be ‘resolved’. It is the engaging with it that is the point. And it is a fundamental and ongoing issue. To give just one instance, how do historians deal with this dilemma of paternalism in regard to their use of the archive?
Cooter, on the other hand, focuses on a different aspect. He lumps all the approaches associated with the past of the history of medicine together because they share assumptions about inequalities of power related to medicine and its recipients. He could criticise the social history of medicine (whether it be of the ‘earliest’ kind, or of the social constructionist kind that emerged a little later) because it wasn't (and still isn't) sufficiently nuanced or reflective about imbalances of power and their manifestation. But he doesn't. This is because the fundamental reason why he unites all the approaches associated with the social history of medicine is deeper and simpler. The problem for him isn't that they were (and still are) insufficiently reflective about imbalances of power, but that they were wrong to have oriented their work around a notion of imbalances of power in the first place. I think he is right, on the whole, in his assertion that approaches in the social history of medicine shared a concern (through its early years, at least) with exposing inequalities of power in society in as much as they related to medical knowledge and practice. I think he is wrong to see this as conceptually illegitimate.
The reason Cooter focuses his criticism of the social history of medicine on its attention to imbalances of power is because he wants to guide the reader, and the history of medicine in general, into taking a Foucauldian position on the nature of power. To put this position in a nutshell: the ‘urground’ of everything for Foucault is power/knowledge. Reality is the ongoing result of power/knowledge combat. So all the concepts that we might try to hang our analytical hats on must submit to this understanding of how power/knowledge creates reality. What now becomes important is not to use the concepts as a means to analysis, but to show how these concepts have been produced, and thus have produced reality.
Using Foucault as paradigmatic, and bringing in other scholars where appropriate, Cooter relays how such concepts as ‘the social’, ‘the political’ and ‘the cultural’ have lost ‘discrete analytical power’. Since he is criticising the social history of medicine, he highlights in particular how ‘the social’ has been revealed as a historical construct.5 The ‘social body’ has been shown to be, for instance, a discursive construct of the nineteenth century. But, as he says, this deconstruction affects wider concepts associated with all intellectual thought. Indeed he notes that ‘vision’, ‘rationality’ and ‘reality’ itself also submit to ‘intellectual disembowelling’.6 So Cooter foregrounds Foucault's work, in particular, as central to the exposure of the conceptual inadequacies of the history of medicine. He can now easily move on from here to proposing that a Foucauldian-inspired approach should be adopted by medical historians.
If there is a key to Cooter's linkage of his criticism of the social history of medicine, with his proposal for its re-fashioning, it is this statement, ‘while the category “the patient” was simply taken for granted, the body of the patient—implicit to all history of medicine—was left largely unattended’.7 Turning-points in narratives often rely on seemingly simple statements like this. To be fair, they are almost impossible to avoid. But let's look at this one. At one level, the statement's power lies in its apparent commonsense. At this level we might agree; of course the body must be ‘implicit’ to any medical work. But even at this level we should be wary. All narratives lead you somewhere. Where is this one leading you? In accepting a ‘basic’ truth of this statement, let's be sure not to be dragged into thinking that this is the only thing ‘implicit’ in all history of medicine, or the only thing worth focusing on. For instance, isn't ‘knowledge’ at the heart of the enterprise as well? Isn't ‘relationship’ too? (Without relationship, there is ‘nothing’ surely?) There must be other examples, but I pick these ones because they are useful to the points I want to make.
Anyway, Cooter doesn't mean ‘the body’ in any ‘innocent’ commonsense way that a person might, at some level, take it. The ‘key sentence’ suggests that we are returning to something more fundamental. But that isn't really the case. Certainly we are not returning to something more reliable and stable; just because ‘the body’ seems more immediate to each of us that doesn't make it so. And Cooter doesn't claim this either. In the passages after what I have called Cooter's ‘key’ sentence, he emphasises that just like, for example, ‘the social’, ‘class’, ‘history’ and ‘power’ (he means power construed in terms of imbalances), ‘the body’ was yet another of those taken-for-granted invariant things. And, given the Foucauldian approach, it is pretty obvious that Cooter's description of the production of reality through power/knowledge must include ‘the body’. So, if ‘the body’ is the important thing that has been left largely unattended to all along, how should we attend to it? The answer is that we are supposed to attend to it, in fact, in the same way as we are supposed to approach ‘the social’, or ‘the ethical’, or ‘class’. That is, we are to analyse it and them only in terms of their production by power/knowledge. What would this history that focuses on ‘the body’ look like? Well, power/knowledge is everywhere; it makes things up, it makes us up. We are power/knowledge fabrications. So what ‘we’ must do is attend to the ways in which we are produced. Cooter refers to Foucault's concept of biopower to describe this power and how it ‘makes us up’; he says it is ‘knowledge-producing processes through which institutional practices come to define, measure, categorize and construct the body and somatically shape all experience, meaning and understanding of life’.8 Now that is a big, big, assertion. Power/knowledge is everywhere, power/knowledge makes everything up, including the very substance and experience of each of us. It is impossible to prove, of course. But there are plenty of seemingly important conceptual understandings that are impossible to prove. So the further question should be: is it persuasive? The answer for me is, no.
In a previous article entitled ‘The Disabled Body’, Cooter says that he is:
Accepting that the human body (like everything else) is what it is, and does what it does ‘because of the categories in which it is conceptualised’, or as Ian Hacking has put it, we ‘make people up’ by the categories we assign or invent for them.9
Is this accepted by most people? Should it be? The sociologist David Armstrong, who likewise employs a Foucauldian understanding of power/knowledge, appears to take a similar view. He sums it up in the tidy sentence, ‘It is the thought that constructs the thinker and the deed that constructs the doer.’10 I don't see any reason to accept this. I don't see it as intellectually sophisticated either. Nor do I believe that it can be proved. I can't resist saying, though, that if it is true, shouldn't the rest of us just pack up and go home? If it is that simple, it surely shouldn't take too long for ‘us’ to be told the ideas and practices that ‘make us up’ at any given time. Though, come to think of it, perhaps it's a bit more complicated: I pick my nose, therefore I am a ‘nose-picker’, so what? This last question is not as gratuitous as it may sound. It points (excuse the pun) to the fact that none of these theorists seems to believe that it is just any old thoughts and practices that ‘make us up’. No, some are more important than others. So, in fact, despite themselves, they place power in a hierarchy. Some powers are more powerful than others, it seems. And so we are straight back to imbalances of power and their effects. But if we accept Cooter's approach, we are in a worse position than before. At least the ‘old’ social history of medicine acknowledged that there can be, and are, power imbalances in the social world that are related to knowledge claims about reality. The proposed new history of medicine leaves this unexamined regarding its own theoretical position.
Take, for instance, Cooter's criticism of Jenner and Taithe.11 I agree with them regarding the ‘new history of the body’. This is indeed ‘all too often a historiography largely devoid of tenderness, of affect, and indeed of respect’.12 Cooter accuses them of a ‘naively realist historical practice that comforts itself in sentimental siding with the silenced’. But this is unjustly dismissive. Paulo Palladino, whom Cooter cites in a footnote, responded to Jenner and Taithe that ‘a more ethical and politically reflective engagement with the silenced might instead begin with the historian's acknowledgement of the power of the hegemonic discourse that silenced them in the first place’.13 This is clearly paternalistic towards whoever the people are whom he calls ‘the silenced’. Worse still, the problem with Palladino's statement is that he, and others it seems, are so enamoured with the intellectual ins-and-outs of the ‘hegemonic discourse’ that they have forgotten all about engaging with ‘the silenced’ at all. What use is that to anyone but themselves? And besides, Palladino and others seem to think they know so much more about the ‘hegemonic discourse’ than any of the so-called ‘silenced’. All of which more likely amounts to a double silencing, doesn't it?
On the one hand, terms like ‘oppression’, ‘society’ and so on are habitually dismissed as wholly lacking in analytical rigour; on the other, massively embracing terms like ‘the Enlightenment’, ‘the modern episteme’, ‘hegemonic discourse’ are bandied around as if somehow they are more cogent. I am afraid this smacks more of institutional fashion than of analytical progress. And it is worth noting that ‘progress’ is exactly what is implied by the substitution of terms in this way. I am not at all sure that I accept the general notion of ‘progress’, but wouldn't Cooter call me naive if I said I did? Besides, isn't this concept of ‘progress’ supposed to be something to do with the ‘Enlightenment’? And doesn't he attack the social history of medicine for not freeing itself from ‘Enlightenment’ discourse?
My annoyance with this sort of wielding of power by theorists relates directly to what I see as the crucial issue regarding Cooter's demand that ‘medico-centric historians’ re-focus on ‘the body’. He describes this necessary attention to ‘the body’ in terms of power, its penetration of everything and, hence, its dispersal of all conceptual solidity. The power/knowledge couplet is deployed, and like others, Cooter chooses to emphasise only one side of it—power. This emphasis serves to deny and replace any other understanding of power. Thus, to attempt to confront imbalances of power, for example, in the care and treatment of aged people, or of people called learning disabled, is likely to draw the accusation, as in the case of Jenner and Taithe, of ‘sentimental siding with the silenced’. Not only that, it will be to draw the accusation of intellectual naivety about the pre-eminent role and nature of power as producer of reality. But why don't we emphasise the other side of the power/knowledge couplet with regard to the manoeuvre that is going on here? From my perspective, what Cooter is really talking about is knowledge. In my view, what he is essentially doing, with this refocus on the body, is switching the basis of knowledge; or rather, he is swinging the pendulum across to one extreme. The effect of this is to deny to individuals in general any authority of knowledge about themselves or, to use Cooter's description of what power/knowledge constructs, their knowledge of their own ‘experience, meaning and understanding of life’. The descriptions of ‘the body’ that follow this theory are inevitably placed in authoritative contradistinction to any particular individual's experience of themselves. As in the responses to Jenner and Taithe, what this does is produce another, and extremely large group of ‘the silenced’. Bluntly, it shuts people up. It does not allow people to speak. What any particular person's life and experience counts as is left in the hands of the people who wield this theory. We are back to imbalances of power again. And, as I said before, this is a worse position than the ‘old’ social history of medicine which, for all its faults, at least recognised that there are power imbalances in the social world that are related to knowledge claims about reality. It comes down to this: will the (newly defined) ‘medico-centric historians’ who are to be the ‘experts’ who wield Cooter's proposed approach, treat people and their opinions about themselves, as potential sources of knowledge about ‘the body’ (‘the self’, and so on) and the world, or is the individual never to be approached as anything other than solely a target for the theory that they hold? To me, it seems like the latter.
The reason I talk about ‘medico-centric historians’ as ‘experts’ who wield Cooter's Foucauldian style theoretical approach is because that is what he suggests. He may want to trash the social history of medicine as a discipline but he nevertheless believes that a new breed of medico-centric historians need to reengage with the ‘contemporary bio-centric world’. And they need to do it with this Foucauldian style theory of biopower that Cooter proposes. According to him, power/knowledge ‘makes up’ our ‘“biosocial” or somatic—body-centred—culture’.14 This connects with his view that,
…we are probably at the most important crossroads in the history of thought since the seventeenth century, and at the most profound shift in the political-economic organisation of the world since early industrialisation and state foundation, and—crucial here—the biomedicine and biosocial processes are deeply implicated in both.15
Since we are at this fundamental shift in thought, and since Foucault has revealed how power/knowledge is the basis of the biomedicine and biopolitics that appear to be at the heart of it, there is clearly a great need to bring together medical historians with a Foucauldian style theory of power/knowledge, and direct them pre-eminently to the issues of the biosciences and biopolitics. I noted earlier that I think there are very good reasons to pay attention to these obviously important areas. But there is no reason to justify such attention on the back of this theory of power/knowledge, nor any reason to restrict the focus of medical historians to such areas by making other foci seem illegitimate. Besides, this reduction mirrors the reductionism of the bio-sciences that I thought Cooter was keen to criticise. He says that:
Unlike the plummeting share price of social history, the exchange value of intellectual engagement with biopower, biopolitics and ‘posthuman medicine’ is steeply rising—and deservedly so. Crucially, these projects matter as never before in human history, and those with training in the history of medicine have the expertise to help make sense of them. Who else, after all, is so experienced at teasing out the contingencies around the material and intellectual making of the body?16
This is to be, then, the history of medicine at a higher turn of the screw. It is no longer the social history of medicine, but the practice of medico-centric historians, armed with a theory of power/knowledge, and directing their ‘expertise’ to the biosciences and biopolitics. Is this a postmodernist response to the postmodern predicament, as Cooter suggests? I don't think so. It is all too modern. He decries ‘the disciplines’ but it is a disciplinary battle by any other name. One of the areas of the social history of medicine that Cooter surely dismisses along with the rest was the attempt to expose the largely hidden politics of professions and professional self-interest.17 We are told often enough, and with justification, that the analysis of professional self-interest, or professional ‘interest groups’, has been punched through with holes in its conceptual apparatus. But perhaps it isn't simply ready for the dustbin just yet? Those still residing in the medical history profession years after the radical assault has lost its power can now happily ask themselves, thanks to Cooter, how can we retain our power in the market place? How can we retain some place in the social and professional hierarchy? And, apparently, not a blush need be seen.
2Cooter 2007, p. 455.
3Cooter 2007, p. 441.
4Cooter 2007, p. 443.
5Cooter 2007, p. 445.
6Cooter 2007, p. 444.
7Cooter 2007, p. 447.
8Cooter 2007, p. 449.
9Cooter 2000, p. 368.
10Armstrong 2002, p. 197.
11Cooter 2007, p. 444.
13Palladino 2001, p. 549.
14Cooter 2007, p. 449.
15Cooter 2007, p. 442.
16Cooter 2007, p. 458.
17Cooter was once one of the participants.