The invasion of hygiene over the past decades has been sweeping, encountering minimal resistance and making its appearance even under the guise of an alternativism that often indulges in hygienic hysteria. According to the experts, therefore, to remain healthy one need only do (or not do) the following: not smoke (and not burden others with one’s smoke), not drink, not eat dietary garbage (but pay double for organic products), exercise (sweating like a lab animal on gym treadmills), undergo systematic medical check-ups (even if experiencing no discomfort), follow the outbreaks of this or that epidemic, and get vaccinated in a timely manner (even if vaccines have not been systematically tested); in short, to remain in a permanent state of vigilance toward one’s own body. And if one eventually falls ill, despite faithfully following the above decalogue, one must be left in the “reliable” hands of these same experts who, of course, know better than the individual themselves what is good for them.
Behind the specialists’ prohibitions and prescriptions, if one looks at them as a whole (even though, as isolated findings, they have a basis), an ascetic-type ideology easily discernible commands a kind of panoramic gaze upon oneself and a self-surveillance to maintain good health. Just as a piece of real estate depreciates when its owner neglects to take care of it, so too does the body itself seem to “lose value” as long as its “owner” does not treat it as a “temple of the soul” requiring regular care. It is not the relentless passage of time with the inevitable decay it brings, nor the environmental pressures beyond individual control that are recognized as causative factors of disease; it is the responsibility of the individual himself who, somehow, somewhere, did something wrong to allow the disease to appear. 1
This obsession with health, of course, shows no signs of abating in recent years. The trend appears to be moving in the opposite direction, toward a direction of overemphasis on medical care, to such an extent that the specific weight of the medical circuit is now causing concerns and suspicions, even at the highest levels, that it constitutes a burden on state budgets. According to a recent report (April 2019) by the World Economic Forum, titled Health and Healthcare in the Fourth Industrial Revolution 2, the cost of healthcare in the U.S. has reached the point of accounting for 17% of their GDP, and it is estimated that the main reason for the increase in this percentage is due to the high cost of technological innovations introduced in medicine (more expensive drugs and devices as well as higher hospital care costs). The authors’ response to this challenge in the report is expected and moves along the basic lines of the 4th industrial revolution: more and smarter technology 3. Genetic engineering, stem cells, immunotherapy, precision medicine 4, nanotechnology, artificial intelligence, big data: these are some of the future technologies that, according to the report, will change the landscape of medicine. In which direction? Here it is (emphasis in the original):
“In the future, two fundamental changes will transform the medical industry. First, healthcare will be provided in the form of continuous, uninterrupted care, transcending the clinic-centered care model with greater emphasis on prevention and early intervention. Second, healthcare delivery will focus on each individual within their own ecosystem, taking more into account people or even the patients themselves, something often referred to as the consumerization of healthcare.”
Expectedly, the report concludes by expressing some stereotypical concerns about the ethical dimensions arising from the application of these technologies and potential unwanted consequences (our emphasis):
“However, these disruptive technologies also have consequences that are unintended and (often) unpredictable. Will new therapies be available only to a select portion of society? If new therapies are expensive, could this worsen existing inequalities in healthcare? Is there a possibility that new technologies, such as CRISPR-Cas9, could be used for enhancement purposes? Will healthcare professionals be adequately prepared to use these new technologies? Could technology disrupt the doctor-patient relationship? Will patient data receive sufficient protection?”
As is evident from the above excerpts, there is no mention whatsoever of a relief of the medical system (of a de-medicalization), but, on the contrary, of a change of model towards an intensification of medical monitoring. And the question that arises here is the following: does this constitute merely an intensification aimed at cost reduction through prevention, or does a different, additional conception of health also emerge?
self-improvement at a biological level
The internalization of a quasi-medical gaze (to use a term from Foucault) toward the self would not have been possible without finding its excess in a diffuse social ideology: that of continuous self-improvement. The internalized medical gaze is simply a variation of this ideology within medical contexts; and (it should be) obvious the affinities of this ideology with liberalism. Already in Locke’s Second Treatise of Government, one of liberalism’s constitutive texts (written in 1690!), the fundamental relationship of the individual to the world is defined as the relationship of possession and property. Not only toward movable and immovable goods but also toward one’s own body. Man is defined as the owner of his body, which he can dispose of as he wishes. It is not within the scope of this text to conduct an exhaustive study of liberalism and its evolution through the centuries following Locke. It is worth noting, however, that the full consequences of liberal ideology began to become apparent almost 300 years later, with the rise of neoliberalism 5 and its post-war transformations. If neoliberalism ultimately managed to place the individual’s priority over society (and his “liberation” from it) at the center, it simultaneously burdened the individual with the responsibility of treating himself as an enterprise; and this not only in his personal economic affairs but in the entirety of his relationships, which increasingly began to take the form of economic transactions. Just as one manages his personal economic “capital” (obviously the term “capital” is grotesquely abusive when we speak of a simple salary, but that is the work of ideology), so he must cultivate and increase his social “capital”; or even the “stocks” of his health. The ideology of self-realization thus reached its peak.
That’s all for today. In the second excerpt from the report we presented above, we emphasized one of the questions: “Is there a possibility that new technologies, such as CRISPR-Cas9, could be used for enhancement purposes?”. Not by chance. The remaining questions, within the known frameworks of medical practice, seem expected. But this question? How could new technologies possibly be used for enhancement, and what does enhancement mean? Although innocently buried among other commonplace concerns, this question may constitute the most important indicator for future directions, both of medical practice and of the very conception of health itself, along with the ideology that will accompany it.
In fact, technology may not have reached the necessary level of maturity yet (although it is close), but ideology is already working feverishly toward a re-conceptualization of health. A classic example here is the movement of so-called transhumanism 6. At its core is the belief that human biological evolution proceeds at a very slow pace compared to the needs of humanity today, and that we cannot afford to wait for it to do its job. Technology now allows the acceleration of evolution through direct biotechnological interventions in the body, towards a new and improved, or more precisely, continuously improving human species. Why should one suffer from diabetes if gene therapy can free them from constant insulin injections? Why should someone waiting for a compatible transplant suffer when it is possible to grow a new organ in the lab from their own stem cells? And ultimately, why should we limit ourselves to the five senses we have known, instead of expanding them, for example, using modified eyes that are photosensitive to other wavelengths, such as infrared radiation? Some enthusiasts of transhumanism have even taken it upon themselves to put its ideas into practice using whatever technological means are currently available. These are the so-called biohackers 7, who, behind a veil of democratizing the biosciences, actively promote in practice the idea of continuous self-upgrade through the fusion of the human body and devices.
At first glance, the ideas of transhumanism might seem naive, reeking of the pungent odor of warmed-over and poorly digested mysticism. Is it indeed the latest mutation of a messianism that once again expects salvation on Earth from the techno-sciences? One could just as easily dismiss biohacking practices as innocent and sporadic experiments by a few fantasists. Opening the doors and lights of your house simply by talking to an implanted chip in your hand still seems far from the point where your eyes could perceive infrared radiation. Yet every industrial revolution began by espousing a powerful ideology, which often verged on fantasy, along with some early “miracles” that may never have fulfilled their initial promises, but which, nevertheless, sparked profound changes.
Examples of serious research towards the logic of biological enhancement can also be found at a more grounded level. In military applications. As part of the BRAIN research program (American brain study research program), DARPA has already initiated in recent years a series of sub-programs aimed at developing technologies (usually in the form of implantable devices) for treating brain disorders that typically affect soldiers, such as post-traumatic stress and memory loss. Treatment, however, is only the initial goal. In the long term, the application of these technologies is also envisaged even in healthy soldiers, with the explicit purpose of enhancing them, mainly in terms of faster training 8. If memory can be restored in patients, then why not use the same methods to improve recall in healthy individuals? As one can understand, if the relevant research is ultimately successful, a huge field of commercial exploitation opens up; but also unique “opportunities” for confusion around the concept of health.
for a mechanic of the body
What is health, then, and why should we perhaps begin to talk about a new understanding of it towards the logic of improvement and upgrading? Just as it is extremely difficult to give a definition of so many other concepts, so it is for the concept of health to give a definition that is diachronic, diachronic and intercultural (the concept of “nature” constitutes another such example, however self-evident it may be perceived today by modern physics). Remaining in what is called the “West”, a dominant medical perception in the ancient and medieval world for centuries was the Galenic theory of the four humors 9 . According to Galen’s theory, just as the world consists of four fundamental elements, so the body consists of four corresponding humors: blood, phlegm, yellow and black bile. The cause of a disease must therefore be located in an imbalance between these humors and each particular kind of imbalance results in the appearance of specific characteristics in the sick individual – the word “melancholy”, which is still used today, comes from black bile; the dominance of this element is supposed to lead to a melancholic disposition. And if disease is the result of an imbalance, then the restoration of health presupposes the restoration of the balance of bodily humors. Even earlier, Hippocrates, considered the father of modern medicine, introduced the skilled observation of patients as a necessary step before diagnosing a disease and formulating a therapeutic treatment. As in the Galenic theory, so in the Hippocratic, the precondition for health was the existence of a balance, that between the individual and his environment. The goal of a therapeutic treatment was again the restoration of this balance.
The details of the above theories are not of particular importance for our purposes here and we will not delve into them. What matters and is worth retaining is the general attitude of the doctor who started from the patient himself and his problem, having an optimistic faith in the forces of nature itself, allowing it to complete its cycle. Any pharmaceutical preparations and interventions served as aids to nature in order to restore the body to its normal function. Hence the reluctance to resort to surgical interventions, which they used only as a last resort.
A real “paradigm shift” in the physician’s attitude only began to occur in the 19th century – and if we are talking about the physician’s attitude and not generally about medical science, the reason is that this attitude is the core of medicine, due to its very nature. The decisive point in this period was the introduction of quantitative methods into medicine, which had already been widespread in physics for almost two centuries. Such a move by itself could be considered progress along familiar and established lines of thought and practice. What truly brought change to the medical attitude was the placement of such quantitative methods at the center of medical practice in an attempt to objectively measure health.
The motivation behind such a gesture was again a kind of optimism, yet of a different nature this time. It was not optimism regarding the healing powers of nature, but rather optimism about the technical ability to manipulate nature, about the capacity to impose human will upon it. It was a transfer to medicine of the industrial spirit of dominating nature; just as a pioneering inventor forces nature to work for his own purposes, so too can the physician handle the body and restore it to its physiological values. The temporal coincidence of the first industrial revolution with the quantification of the body should probably not be considered accidental.
The consequences of this gesture were decisive for the change in medical stance. Firstly, the doctor was invested with an unprecedented authority over the patient, introducing an insurmountable gap in knowledge between them. It is not the collaboration of the doctor with the patient—and both of them with nature—that will allow healing. Now we have to deal with a quasi-warlike conception of the therapeutic process. The doctor fights the disease with the precision of his knowledge, perhaps even against nature—which, in any case, follows its course and its laws in both pathological and normal conditions—but many times even against the will and limited knowledge of the patient. The patient has become a mere bystander; the essence lies in the disease itself, which is the object par excellence of knowledge.
Secondly, since nature always follows its laws, then the distinction between the normal and the pathological, between health and disease, becomes questionable. A body follows the same laws whether it is ill or healthy. Nature always functions in the same way. And thus a continuity is established between the physiological and the pathological, which was not only a consequence of quantification but simultaneously its precondition. In order to determine the physiological values of whatever measurements and secretions of the body, the body first had to undergo a homogenization along a measurement axis. Just as the new mathematical physics could not tolerate different qualities in space and had to “flatten” it into homogeneous coordinates, likewise 19th-century medicine could not tolerate different qualities in the condition of the body. Disease was a deviation from physiological values; a deviation that happens to be undesirable from the subjective perspective of the patient and therefore must be moderated, but which, otherwise, from an objective point of view, when the physician’s gaze becomes purely scientific, constitutes nothing more than a quantitative differentiation within a continuum.
the ascent to the heaven of health
Based on the above reasoning, the ideal for medicine to ultimately transform into a pure and objective science would be the elimination of the patient’s subjectivity. However much medicine has progressed on the path of quantification, if it did not want to abolish itself, it had to respect the boundary between physiological and pathological. A doctor who would examine and treat corpses and living people in the same way would simply be a necrophile and certainly not a doctor. For medicine to become a strict science, for the doctor to become master and owner of his object, it seems that he first needs to eliminate the object itself. The annoying subjectivity of the patient, who, ultimately, chooses when to seek medical care, persists in standing as an obstacle. In this ambivalent condition, medicine has remained until today.
If therefore the quantification of medicine encounters its limits in the ineliminable subjectivity of the patient, could another path be found to ascend to the heavens of health? If, before the body becomes an object of measurement and handling, this subjectivity could first become an object of handling? The first steps have already been taken. When, according to the dictates of hygiene, every individual is called upon to adopt a stance of vigilance toward their body for possible signs of illness, then the spectrum of disease, even as suspicion, expands to encompass space from the field of health. And if the primary subjective experience is indifferent to the definition of disease – if, in other words, feeling good has no bearing on whether you are actually well – then you may be ill without knowing it. The ultimate conclusion of these steps altering the subjective stance toward the body is that everyone is permanently ill or at least potentially ill. Ill until (always provisional and reversible) proof to the contrary, with the burden of proof now falling on the doctor and the measurements of his instruments. If the continuous, uninterrupted care, according to the authors of the World Economic Forum report, seems (and is presented) as an attractive solution toward preventive medicine, it will simultaneously function as a powerful multiplier of all hypochondriac tendencies that have already been systematically cultivated over recent decades.
And if hygiene has cultivated the ideological groundwork from the side of illness, the new logic of biological enhancement and improvement attacks subjectivity from the side of health, promising to open up vast areas of commercial exploitation where health will not even be a difficult but nevertheless achievable and unambiguous ideal. The race will not only be against disease (and a continuous suspicion of disease) but also for the enhancement of health. Whoever can perceive infrared radiation will be “healthier” compared to a traditional and non-upgraded model of homo sapiens; however, “less” healthy compared to someone who can also perceive ultraviolet radiation. Through such a relativization, health loses its inalienable value and may even eventually be priced, ultimately transitioning from the quantification of the body to the quantification of health itself.
The particular example we have chosen seems to be taken straight out of a science fiction scenario, and it is indeed possible that the relevant technologies may take some time to reach such a level of maturity. However, less exotic technologies are already knocking at our doors. Without yet penetrating deeply into the body (for instance, genetic modifications have not yet reached the required level of precision, though this is already beginning to be addressed with technologies such as CRISPR), all of them tend toward a closer integration of the biological–organic and the mechanical–informational. And here a first issue immediately arises regarding the ownership of any health surplus that a relevant technological application may offer. Who exactly will be its owner? In the substantial, not necessarily legal, sense of the term. If the devices, with their functions and their own upgrades, do not belong to the body, then does the user perhaps become merely a custodian, but not truly the owner, of their own health?
It might be too early for such conjectures, however there is another issue regarding the relativization of health and ultimately an imposed definition of it from above. It may not be so obvious, but both illness and health incorporate pieces of social memory; and indeed with the literal meaning of the word “incorporate”. We quote two excerpts from Georges Canguilhem’s book, “The Normal and the Pathological” (emphasis in the original):
“If it is true that the human body is, in a sense, a product of social activity, it is not arbitrary to assume that the stability of certain characteristics, which a mean value demonstrates, depends on conscious or unconscious conformity to certain rules of life. Consequently, as far as the human species is concerned, statistical frequency expresses not only a vital regularity but also a social regularity. A human characteristic is not normal because it is frequent, but it is frequent because it is normal, that is, regulative within the framework of a way of life.
…
However, we believe that there is nothing in science that has not previously appeared in consciousness and, in the case that particularly concerns us, that it is the perspective of illness that is fundamentally the true one. And here is why. Doctors and surgeons have clinical information and also frequently use laboratory techniques that allow them to identify as patients people who do not feel such. This is a fact. But it is a fact requiring interpretation. The healers of today are able to anticipate and surpass in clinical insight the ordinary or occasional patients of today only because they are the heirs of a medical education transmitted to them by the healers of yesterday. Upon final analysis, there has always been a moment when the attention of healers was drawn to certain symptoms, even absolutely objective ones, by people who complained that they were no longer normal, that is, the same as their past selves, or that they were suffering. If today the physician’s knowledge of illness can anticipate the patient’s experience of illness, it is because at some point the latter prompted the former, challenged it. Medicine therefore has always existed de jure, if not today de facto, because there are people who feel ill – and not the other way around.”
We are therefore speaking of a dual social memory, both at the experiential level of health and illness, since both involve a dimension of social normativity – in other words, the kinds of illnesses and the physiological norms of measurements are defined in direct correlation with the way (among all possible ways) and the rules that a social group has chosen to live by – as well as at the level of therapeutic techniques. Viewed from this perspective, insistence on a logic of self-improvement (the terms of which are obviously imposed from above) also constitutes an assault on social memory, since this social memory becomes, if not useless, certainly of lesser significance, with the gaze always turned toward the future. And if illness and health disorders represent a condensation of the past, even as its negative imprint, then they could also be considered fundamental pathways toward individual and collective self-awareness. The persistent gaze toward the future, toward the next upgrade, however much it may deny it, always implies, as a hidden concession, a depreciation of the past. The justification of the future, severed from the past and its traumas as the necessary points of reference, loses its substance and degenerates into a solipsistic self-reference. The future can only be justified by “more future.” This is the old, good recipe of every bad metaphysics. And it is also the definition of the good health of the machine: the machine of capitalist expansion.
One question, however, remains pending. Speaking about human health, does referring to its social contexts inevitably lead to the vicious cycle of an unchecked relativism? Is it ultimately possible to provide a definition of health? Following Canguilhem once again, the answer is affirmative; yet it does not take the form of a formal definition, as one might expect. According to Canguilhem, health is the ability of an individual (or a group) to establish new rules of life for oneself10, to exploit one’s current state of health in order to transition to another. Health is a capacity for self-determination (and not some naive idea of self-realization) within the framework of an already existing network of constraints, but never a demand for the continuous realization of all potentialities. A permanent state of alert, the constant anxiety about health and self-maintenance – and here it is worth recalling popular theories of life as a perpetual struggle for self-preservation – is already a sign of an organism’s failure to adapt to its environment; in other words, already a state of illness.
Behind the fanciful wrapping of perpetual upgrading, with all its promises of transcending human nature, lies the crutch of permanent disease and the tangled strands of a guilt complex toward the body. It resembles almost another transformation of original sin. Needless to say, promises of bodily liberation will soon prove to be bounced checks. Some, however, will have already cashed in, and the checks will bounce in the hands of those who prove overly eager to upgrade themselves to homo sapiens 2.0, 3.0, …
Separatrix
cyborg #15 – 6/2019
- At first glance, this asceticism of hygiene appears to conflict with the simultaneous imperative call to consume unhealthy products, which also constitutes a constant pattern in mature capitalist societies. It is clear that no individual can permanently follow both these tendencies at the same time. However, another behavior is possible, one that functions as a feedback loop between these two tendencies: that “bipolarism” whereby one can engage in excesses for certain periods and then return, burdened by guilt syndromes, to healthy habits; always remaining in this ambivalence (starting a diet every Monday…). And so both the circuit of hygiene and that of junk profit. ↩︎
- It can be found here ↩︎
- For an explanation of the reasons why the demand for more technology will not result in any democratization of medical care, nor (most likely) any reduction in its cost, but perhaps only some redistribution of it, see Ivan Illich’s book “Medical Nemesis. The Expropriation of Health.”, published by Nisides, translated by V. Tomanas. ↩︎
- See Cyborg, vol. 9, precision medicine: the personalization of medicine. ↩︎
- The existing affinities between classical liberalism and neoliberalism at the social level should not lead to the easy conclusion that they have equally close affinities at other levels. At the political and economic level, they have significant differences. We will not elaborate here, but we make this observation to avoid easy misunderstandings. ↩︎
- Cyborg, vol.1, The possibilities of transhumanism and vol.4, Human plus (human, very human…). ↩︎
- See Cyborg, vol.10, DIYbio: self-enhancement in the 21st century. ↩︎
- One can see for example the RAM (Restoring Active Memory) and TNT (Targeted Neuroplasticity Program) programs. ↩︎
- Far and away the most important work (from those we have in mind) for a “critical epistemology” (if the term “critical epistemology” is not an oxymoron) of medicine and particularly of the concept of health is the book by Georges Canguilhem, “The Normal and the Pathological”, ed. Nisos, trans. G. Fourtounis. From there and the elements we have drawn regarding the “change of medical paradigm.” The book by Illich we mentioned above is also important. Particularly for the institution of the clinic, Foucault’s well-known book, “The Birth of the Clinic”, ed. Nisos, trans. K. Kapsabelis, is also of interest. ↩︎
- It is interesting that this definition of Canguilhem is essentially a meta-definition (with a strong social flavor), adaptively flexible across historical periods and places, and not a rigid definition with specific magnitudes and values. In this way, it resembles the Kantian definition of moral action, which likewise does not essentially define a morality, but rather a meta-morality. ↩︎