2Encodingneoliberalreciprocity Connectingpatient,governmentandsociety

InPart1,Iindicatedtheimportanceofneoliberalismforunderstanding Dutchhealthcareinnovation.Inthischapter,Icontinuethislineofthedis cussion.Withrespecttothepracticallensofthischapter,thisdenotesa studyofneoliberalelementsintheplanningofaninfrastructureforaDutch electronichealthrecord.Wewillseethatsimilarmechanismsareatworkas whatIshowedforthetoolstomeasureinnovation. Theoretically,Istartthediscussionofthesecondmodeofsubjectiva tionthatiscentraltoPart2ofthestudy:reestablishingpowerrelationsin society.Anunderstandingofthemannerinwhichneoliberalismattemptsto recreatesuchrelationsisessentialforgraspingsubjectivationinpostpanop ticism.Iposethatneoliberalismisatypeofpostpanopticalpoliticalandeco nomicthought.InthepreviouschapterIalreadyindicatedthatstagedfree domiscentraltosuchawayofthinking.Inthischapter,Idevelopthisno tion. Theframeworkforthischapterisbasedonthescatteredremarksthat Foucaultmadeaboutreciprocityinaneoliberalcontext.Iamparticularly interestedinthemannerinwhichideasaboutreciprocityareusedincreating blueprintsforanewgovernmentality.IusethisconcepttoindicatethatI refertothepolicyplanningstagehere.JustlikeinFoucaultsworkonneolib eralism,thefocusisonconceptualisation,ratherthanonimplementation. However,byconnectingthenotionofblueprintstothedesignoftechnology theelectronichealthrecordIstudyattemptstomaketheconceptualisa tiondurable,touseLatourstermagain.Intermsofthetitle:Istudyat temptstoencodeneoliberalperceptionsofreciprocityinthetechnicalinfra structureoftheelectronichealthrecord.Inthischapter,Imainlyrelyon documentsthathavepassedthroughparliament.Infollowingchapters,I broadenthisscope. Withrespecttothebroaderunderstandingofpostpanopticism,myar gumenthereisthatattemptsaremadetousenewtypesofinformationtech nologytoenforceagovernmentalitythatisdifferentthanpanopticism.In thisrespect,technologicaldevelopmentsareintertwinedwiththeshiftfrom onetypeofgovernmentalitytoanother.Thisisnottosaythatadifferentori entationinpoliticalthoughtcausedthedevelopmentofdifferenttechnologies, 69

Encoding neoliberal reciprocity. Connecting patient, government and society

ortheotherwayaround.Suchshiftstypicallycooccur.Inthenextchapter,I willbeabletocomebacktotheimpactofsuchlongtermdevelopments.We alsohavetobecarefulnottoimaginesuchshiftsasbreaks. Cautioniswarrantedhere.Theideaofmaterialisinghumanconceptions evokesthesubjectobjectdichotomythatthinkerslikeLatourhaverightfully resisted.Itrecallsmuchcriticisedsocialdeterministviewsoftechnology,or viewsofmaterialiseddiscourse.Thisisparticularlythereasonforstressing thenotionofblueprints:thesenecessarilyhavethestatusofplans.Inthefol lowingchapters,theseattemptsathumanconstructionarequestionedstep bystep.Anothercautionarynoteisthatthereisadangerinfocusingontech nologyasaninfrastructure(Barry,2001).ItquiteeasilyevokesaMarxistim ageofatechnologicalbaseonwhichsocialsuperstructuresarebuilt.Ido notsharesuchaviewoftechnology.Nevertheless,suchanapproachdoes seemtounderpinpoliticaldiscussionstoagreatextent.Assuch,itwouldbe ashametoignoreit.Alsohere,thelogicisthatIfocusonattemptstocreate infrastructures.Inlaterchapters,Iquestionthefeasibilityofsuchattempts,in relationtosubjectivation. Reciprocityisacentraltopicinsocialtheory,andistypicallyhardtodefine (Gouldner,1960).Itisnotmyaimtodefineithere,eventhoughafewmini malcommentsarenecessarilytoplacethefollowingintocontext.Along historyofresearchhasshownthatitisdangeroustosimplyregardarecipro calexchangeasasetofmutuallybeneficialactsofgenerosity.Particularlythe anthropologicalstudyofgiftexchangehasbroughtforwardthatinsomeso cietiesapresentisamisfortunebecause,inthefinalanalysis,itmustbere ciprocated(Bourdieu,1998,p.94).Ontheotherhand,itisparticularlythis notionthatmakestheperceptionofvalueofgreatimportanceintheunder standingofreciprocity.Inordertoknowhowtoreciprocate,insuchasoci ety,thevalueofthepresenthastobeassessedratherprecisely.Inthissense, anexchangeisonlyreciprocalifitismutuallyappreciatedasreasonable. Inthischapter,IfollowMichelFoucaultsaccountofthehistoryofthe reciprocityconceptinpoliticalthought.Thisisinterestingfordifferentrea sons.Theoretically,reciprocityishardlyrecognisedasathemeinFoucaults work,probablybecausehedealswithitsomewhatimplicitly.Onlywithre gardtohisdismissalofhumanismwecanfindsomediscussion.Hooke (1987),forinstance,arguesthatFoucaultmaintainsbasichumanvalues,such asreciprocity,whilerejectingmodernhumanism.Hefurthermorestatesthat:

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Foucaultdoesmorethanmentionthethemeofreciprocity.Heis oftencriticalwhenitisdistortedbecauseindividualsareplacedin circumstanceswherebytheirchancesofunderstandingwhatis happeningtothemorchoosingtheiractionswithinthecircum stancesaredecreased(1987,p.41). Iagreewithsuchapointofview,andarguethatreciprocityisgenerallyim portantinFoucaultswork.Itshedslightonhowreciprocityisconstituted withinanetwork,ortopologyofpowerrelations(Collier,2009).Aswith mostofFoucaultsanalyses,suchanapproachcanserveasacounterhistory tothehumanistreadingofmodernitythatheopposes. Practically,Foucaultsideasonreciprocityarerelevantasareflectionon recentpolicydevelopments,particularlyneoliberalism.Hejuxtaposesmid 20thcenturyformsofneoliberalismmainlyGermanOrdoliberalismandthe AmericanChicagoSchooltotheclassicalliberalismofthe17thand18thcen tury(Gane,2008).Nevertheless,thereisclearlyagreatcontinuityofearlier liberalthought.Thisiseasilyoverlooked.Despiteafewpointsofcriticism (Tribe,2009),orremarksaboutomittedpartsofrelevance(Lazzarato,2009), thereceptionbyeconomistsofFoucaultsworkinthisareaseemstobegen erallypositive. Fromthepointofviewofreciprocity,itisparticularlyinterestingthat Foucaultarguesthatneoliberalismabandonedthenotionofexchangeasthe centraldenominatorofeconomicthought.InTheOrderofthings(Foucault, 2002),whichIreferredtointhepreviouschapter,theimportanceofexchange inmodernthoughtisexplainedinrelationtothequestionoflabour.Inneo liberalism,competitionbecamethenewparadigm.Animportantquestion forthischapterishowreciprocityisconceptualisedifthefocusonexchange isabandoned. Theapproachofthischapteristoprovideamoresystematicaccountof atopicthatFoucaultdealswithsomewhatimplicitly.Idothisbydistinguish ingfourformsofreciprocity:betweenindividuals,betweenindividualsand thepopulationincivilsocietybetweencivilsocietyandgovernmentand betweenindividualsandgovernment.Thesefourtypesaresubsequentlyap pliedtotheplanningoftheinfrastructureforaDutchelectronichealthre cord.Concretely,thisimpliesthatIstudyhowattemptsaremadetotranslate aparticularconceptionofreciprocityintoascriptthattherecordwouldcarry out.Suchanapproachofstudyingtheinscriptionofvalues,interestsorvi sionshassomehistoryinthestudyofelectronichealthrecords(Hanseth& Monteiro,1997).Clearly,thesamecautionaryremarkapplieshere:human 71

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inscriptionsoftenfail.This,however,isthetopicofPart3.Throughoutmy discussion,Irelatereciprocitytothequestionoftheneoliberalsubjectthat Foucaultevokes(Read,2009)andmaketheconnectionwiththetwosubject typesthatIdiscussedinthepreviouschapter.

Towardsaneoliberalviewofreciprocity
Acrucialpointforunderstandingchangesinthepoliticalunderstandingof reciprocity,accordingtoFoucault,iswhenpoliticalscholarsceasedtothink intermsofasocialcontract,asdevelopedbythinkerslikeHobbes,Lockeand Rousseauinthe17thand18thcentury.Dependingonwhichcontracttheorists werefollowed,thisimpliedavoluntaryagreementbasedonthewillofindi vidualstoconstituteasocietyorasovereignruler.Ithasbeenrecognisedthat thenotionofthesocialcontractplayedafundamentalroleinFoucaults thinkingaboutreciprocity.Hookearguesthat: [w]eneedtounderstandhowFoucaultseeshumanismparticipat ingintheruptureofpossiblereciprocalrelationsamonghumans. FundamentaltoFoucaultsviewisseeingthatwhatisdistinctivein humanismsinterpretationofthehumanvaluesisthemediationof thesocialcontract(1987,p.42). Itwasthesocialcontractthatchangedboththeideasabouttherelationsbe tweenindividuals,betweenindividualsandthepopulation,andbetween civilsocietyandgovernment.Theideaofthismediationisthatreciprocity doesnotonlyexistbetweenindividuals,butalsobetweenindividualsand society.Whilecrime,forinstance,waspreviouslyconsideredasanattack againstthesovereign,withtheintroductionofthesocialcontractconstructit wasconceptualisedasanattackagainstsocietyandallitsmembers.Inother words,aninstitutionalisedformofreciprocitywasassumedbetweenindi vidualsandsociety.Inwhatfollows,IshowthatFoucaultnotedthatoneof themostfundamentalinnovationsofneoliberalismwastoabandontheno tionofasocialcontract. Iexplainhowwecanunderstandboththecontinuityanddiscontinuity inthedevelopmentfromsocialcontracttheorytoclassicalliberalismand neoliberalism.Assaid,Isubdividethisbylookingatdevelopmentsinthink ingaboutanumberofdifferentrelationsofreciprocity.Sometimes,however,

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thesedifferenttypesareinterrelated.Thisparticularlyrelatestotheinvolve mentofgovernment.Inotewhenthisisthecase. Reciprocitybetweenindividuals Thefirsttransitionfromcontractthinkingtoneoliberalismisthatreciprocity wasnolongerthoughtofasbeinggroundedinlaw,butasbeingdrivenby interest.Anearlydebateonliberalviewsofcontracttheorydealtwiththe questionofwhyindividualswouldbeinclinedtorespectacontractonceit wasinstated.Eventhoughtherewasgeneralagreementthatindividualsen terthecontractbecauseoftheirpersonalinterests,therewasadifferenceof opiniononrespectingitafterwards.FoucaultreferstoBlackstonesargument ofrespectingthecontractforthesakeofitbeingacontract,andmentions Humesargumentofrespectingthecontractbecauseoftheinterestinmain tainingthelevelofsecuritythatitoffers(2008,p.273).Foucaultexplainsthis distinctionbypointingatthedifferentmodelofmanthatthisimplies:the formerbeingasubjectofright(homojuridicus)andthelatterbeingasubject ofinterest(homoconomicus).Thesubjectofinterestcouldbreakthecontract ifitwasnolongerinhisorherinterest.Thisisclearlyamoreliberalviewof contracttheory,butonethatpertainstoaclassicalformofliberalism.Later forms,includingneoliberalism,rejectsocialcontracttheoryaltogether.Obvi ously,thisdoesnotimplythattherearenocontractsorotherformsofjuridi calagreementsinneoliberalism.Abandoningsocialcontracttheoryeffec tivelyimpliesthattheideaofapurposefulbondbetweenindividualsisre placedbyanimplicitone,whichistheunintendedoutcomeoftheinterplay ofindividualinterests.Thisstructureisessentiallyegoistic(McNay,2009), butisstillconsideredreciprocal. Anotherdevelopmentthathasprobablybeenimportantintermsofidea aboutreciprocityisthehistoricaldevelopmentinthinkingaboutthecentral organisingprincipleofeconomiclife.Overtime,thisshiftedfromexchange tocompetition.Thisdoesnotimplythattherewasnocompetitioninthe exchangeera,andviceversa.Itisratherthatthewayofthinkingabout theseconceptschangedovertime.Foucault,however,contradictshimself whendiscussingthetimeatwhichthisshiftoccurred.Ontheonehand,he referstothecompetitionparadigmasoneofthethreedefiningcharacteristic thatsetsneoliberalismapartfromclassicalliberalism(2008,p.118).Onthe otherhand,heparticularlytracesbackthesechangingperceptionstoclassical economistslikeAdamSmithandAdamFerguson.Itseemstomethatthe 73

Encoding neoliberal reciprocity. Connecting patient, government and society

correctinterpretationisthattheprinciplewasdevelopedaroundthemid18th century,butthatitwoulddevelopintoanomnipresentparadigmonlylater. Thisistoagreatextentduetoconnectingthethemeofcompetitiontoentre preneurship.TheGermanincarnationofthiswayofthinkingwastoregard thefamilyastheidealsmallscaleentrepreneurialunit.Thisconceptionis largelyduetoitslinkstoChristianpolitics.TheAmericanform,bycontrast, believedtheindividualtobeanentrepreneuroftheself.Thisimpliesan outlookatallaspectsofoneslife,asifitwereanentrepreneurialventure. Oneseducation,onesrelationsrequireaformofmanagementsimilartothat ofabusinessenterprise.Thisstronglyechoesthetheoryofinvestinginhu mancapital,whichIexplainedinthepreviouschapter.Goodeducationfor oneschildrenbecomesaninvestment,whichwillleadtofuturepayoffs. Then,whatdoesthischangedperceptionofcompetitionimply?Upto mid18th,theinfluenceofmercantilismimpliedawayofthinkingthaten tailedthatcompetition[could]onlybeconceivedintheformofazerosum gameandsooftheenrichmentofsomeattheexpenseofothers(Foucault, 2008,p.53).Afterthat,awayofthinkingwasintroducedthatmadecompeti tioncompatiblewiththeideaofreciprocity.Foucaultarguesthat: forthephysiocrats,butalsoforAdamSmith,thefreedomofthe marketcanandmustfunctioninsuchawaythatwhattheycallthe naturalpriceorthegoodpricewillbeestablishedthroughand thankstothisfreedom.[This]willbeprofitabletotheseller,but alsotothebuyer(2008,p.53). Whatweseehereisawayofthinkinginwhichreciprocityisnolongerbased ontheobjectthatwasexchanged,asintheexamplesofgiftexchangethatI notedintheintroduction.Instead,itisbasedonthewayinwhichtherelation ofexchangeisshapedbycompetition. Inliberalthoughtthatprecededneoliberalism,itwasacknowledged thatthefocusonselfinterestednesswouldcollidewithothervaluesthata personmayhave,suchasfeelingsofbenevolenceforothers.Therewasstilla distinctionbetweentheeconomicsubjectandtheindividual.Forneoliberal thinkers,however,particularlyforaneconomistlikeGaryBecker,thisdis tinctiondisappeared.Eveninterpersonalvaluescouldbeexplainedinan economicmanner.Forinstance,inhisdiscussionoftheeconomicsofmar riagehearguedthatthereciprocalrelationsbetweenhusbandandwifemay wellbeexplainedontheexclusivebasisoftheprinciplesofself interestednessandrationality(Becker,1976). 74

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Reciprocitybetweenindividualsandthepopulation Foucaultrelatestheriseofthepopulationasanunitofgovernancetothede velopmentofstatisticsandpoliticaleconomyaroundthehalfofthe18thcen tury(Foucault,1991).Hedefinespopulationasagroupofbeingslivingina givenarea(Foucault,1979,p.252).Inthemodelthatwastoreplacethetradi tionalconceptionofsovereigntyanditsartofgovernment,thewelfareof thepopulationbecamethehighestend,whichwastobeachievedbymeans ofpoliticalscience.SomehavearguedthatFoucaultapproachespopulations moreandmorethroughitsindividualelements(Tellmann,2009).However, whenitcomestogeneratingknowledgeinrelationtothebuildingofpower, theindividualandthepopulationgetseparateattention.Hedistinguishes knowledgethatisglobalizingandquantitativewhenthepopulationiscon cernedandananalyticaltypeofknowledgeofindividuals(Foucault,1982). Inordertounderstandhowindividualsrelatetothelargerwholeofthe population,orcommunity,Foucaultdescribestheideasofdifferentauthors oncivilsociety.Contrarytocontemporarycivilsocietyscholars,Foucault stressesthewayinwhichearlythinkersregardedcivilsocietyastheplay groundofeconomicrelations.Heexplainshowthisconceptchangedmean ingsovertime.Uptothemid18thcentury,itwasconnectedtothejuridical setupthatIoutlinedbefore,forthinkerslikeJohnLocke,forexample.After wards,authorslikeAdamFergusonandAdamSmithregardeditasanag gregateconceptthatfixedthespontaneousrelationsbetweenindividualsand thepopulation.AdamSmithsinvisiblehandisprobablythebestknown descriptionofthiswayofthinking.Ratherthanrelyingonformalagree ments,therewouldbeaspontaneoussynthesis,oradefactoeconomic bondbetweenmen(McNay,2009,p.69)insocietyasaresultoftheinterplay ofindividualandcollectiveinterests.Theassumptionisthatthenaturalde velopmentofpowerrelationsplaysthespontaneousroleofthesocialcon tract(Foucault,2008,p.303).Hecontinuesbysayingthat: thereisnoneedofapactumunionistojoinindividualstogetherin civilsociety,soforpoliticalpowertoemergeandfunctionwithin civilsocietythereisnoneedofapactumsubjectionis,ofthesurren derofcertainrightsandtheacceptanceofsomeoneelsessover eignty.Thereisaspontaneoussynthesisofpower.Howdoesthis comeabout?Itisbroughtaboutquitesimplybyadefactobond whichlinksdifferentconcreteindividualstoeachother(Foucault, 2008,p.303). 75

Encoding neoliberal reciprocity. Connecting patient, government and society

AsIsaidbefore,therewasabeliefinanautomaticformingofcompetitive, butreciprocalrelationsbywhichindividualswouldfindtheirpositionin civilsociety.Thisreciprocity,however,wouldextendbeyondtherelation betweenindividuals.Foucaultstressesthatthereisanassumptionof reciprocitybetweenthewholeanditscomponents[..W]ecannot imagineorconceiveanindividualtobehappyifthewholeto whichhebelongsisnothappy.Better,wecannotevenassessex actlyanindividualsquality,value,andvirtue[..]unlesswethink ofitonthebasisoftheplaceheoccupies,theroleheperforms,and theeffectsheproduceswithinthewhole.Everyelementofcivilso cietyisassessedbythegooditwillproduceorbringaboutforthe whole.Wecansaythatamanisgood,thatheisfineonlyinsofar asheisrightfortheplaceheoccupiesand,Fergusonsays,pro ducetheeffectitmustproduce,Butconversely,thevalueofthe wholeisnotanabsoluteandisnottobeattributedtothewhole andonlythewhole,buttoeachmemberofthiswhole:itislike wisetrue,thatthehappinessofindividualsisthegreatendofcivil society(2008,p.301). Weseeawayofframingthatisverysimilartooneofthetwosubjectivations thatIdiscussedinthepreviouschapter:thehumancapitalsubject.How ever,byreconceptualisingitintheframeworkofarelationofreciprocity,the imagechangestosomeextent.Suddenly,thereisarationaleforwhypeople shouldaccepttheirroleascoginthewheeloftheeconomy:theideathatcivil societytreatsthemwellinreturn.Nevertheless,wehavetonotethatitis hardlyclearhowthisisexpectedtoworkinpractice.Wehavetokeepthe optionofrhetoricopen. Toagreatextent,thiswayofthinkingwasadoptedinneoliberalismas well.Thedifferenceismainlythattheassumptionthatpowerrelationsand reciprocitywouldoccurspontaneouslywasdropped.This,however,relates toyetanotherwayofthinkingaboutreciprocity,i.e.intherelationbetween governmentandcivilsociety.Ireturntothatbelow.First,Iattempttofinish mydiscussionofreciprocitybetweenindividualandpopulation. Ifallconductisexclusivelybasedonindividualinterest,asisimagined byseveralneoliberalthinkers,thencollectivegoodsmustneverbeanobjec tiveforindividualcitizens.ThesearelefttotheState.Asaresultofthis,col lectivevaluesaresaidtohavebeenlostinneoliberalism(McNay,2009).Still, 76

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itisassumedthatbypursuingtheirowninterests,individualsunintention allycreatebenefitsforsocietyaswell.Reciprocitytakesanimplicitform.This isaratherawkwardnotion,particularlyconsideringthedescriptionthatI gaveofreciprocityintheintroductiontothischapter.Ifreciprocityissoim plicit,itcannotreallybeassessedbyindividualsanymore,aswasthecasein theexampleofgiftexchange.Obviously,wecanimaginespeakingingeneral termsaboutthemutualbenefitsthatindividualsandsocietyreceiveintheir engagements.However,ifwefollowsuchacalculativemodeofthinking,for bothpartiesitishardtodecidewhethertheirbenefitsseemtobeinbalance. ThefinaldevelopmentIwanttohighlighthereisthatneoliberalthink ersclaimthatbondsbetweenindividualsandcollectivesaremediatedbythe rulesofaneconomicgame.Thisislargelyintertwinedwiththedevelopment ofgametheory,whichdevelopedincloseproximitytoneoliberalism.Think tanksliketheRANDcorporationhadasubstantialimpactonthis(Amadae, 2003).Moreingeneral,itisconnectedtotheadoptionofrationalchoicethe ory,whichcouldbeappliedtoanythinginthewiderangefromcrime,to wagesintheworkplaceandmarriedlife,asIsaidbefore.Theimportanceof thisisthatinbothcontracttheoryandintheneoliberalconceptionofrecip rocitythereisanotionofrulesthatgoverntherelation.Inthecaseoftheso cialcontract,however,thesearerulesthatwereimaginedtohavebeenpur posefullysetbetweenindividuals.Intheneoliberalconception,bycontrast, therulesofthegameareexternaltocivilsociety.Inclassicalliberalism,it wasstillexpectedthatsuchrulesweregivenbynature,recallingthefaithin aspontaneoussynthesis.Forneoliberals,itisthestatethatneedstosetthe rulesofthegame. Reciprocitybetweengovernmentandcivilsociety Theshiftfromreciprocitybasedonajuridicalagreementtoonebasedonin terestsalsoimpactedthethinkingabouttherelationbetweengovernment andcivilsociety.Foucaultsdescriptionofthedevelopmentinideasonwhat hecallstheinternallimitationofgovernmentclearlycapturesthisphe nomenon.Intheeraofjuridicalconceptionsofgovernment,stateswerecon sideredtobelimitedbyextrinsiclawsbothnaturalandpositiveonesin theirsphereofinfluence.Therewerecertainareasinwhichnoinfluence couldbeexerted.Theparticulartheoryofthesocialcontractevenassumed thatsuchlawswereformedinagreementbetweenthepopulationandgov ernment.Thereciprocalrelationthatisimpliedhereisthatcitizenstransfer 77

Encoding neoliberal reciprocity. Connecting patient, government and society

someoftheirrightstogovernment,inordertoreceivetheprotectionofthese andotherrightsinreturn. Withtheabandonmentofsuchjuridicalwaysofthinking,infavourof onescharacterisedbyinterest,thethoughtarosethatgovernmentsoughtto belimitedintrinsically,ratherthanbyanoutsidesource.Thisdevelopment coincidedwiththeriseofutilitarianism.Itledtothinkthatthewelfare,con dition,longevityandhealthofthepopulationoughttobethemainobjective ofgovernment.Governmentalactionshadtobejustifiedbymeansofthe utilityofindividualsandthegeneralutility(Foucault,2008,p.44).Foucault claimsthatthisprinciplehasturnedintoanallcompassingelementofour age,replacingthenotionofnaturalrightsofcitizens.Theinternallimitation ofgovernmentinthisframeworkmeansthatgovernmentalactionisonly thoughttobejustifiablefromautilitarianperspective.Foucaultconnectsthis totheriseofpoliticaleconomy,whichcreatedmodelstomeasurethefunc tioningofgovernment.Thereciprocalrelationinthisrespectchangesinto allowinggovernmenttoexertpoweraslongasitisintheinterestofthe populationanditscitizens.Inordertounderstandhowgovernmentandcivil societycanassessthereciprocityofsucharelation,weneedtounderstand therelationbetweengovernmentandindividualfirst.Thisisdiscussedun derthefollowingheading. Thecomingofneoliberalism,finally,impliedthatthenotionofthestate andtheeconomyasseparatedomainswascompletelyannulled.Foucault arguesthat: Therewillnotbethemarketgame,whichmustbeleftfree,and thenthedomaininwhichthestatebeginstointervene,sincethe market,orratherpurecompetition,whichistheessenceofthe market,canonlyappearifitisproduced,andifitisproducedby anactivegovernmentality(Foucault,2008,p.121). ThisprovidesagoodlinktothelastformofreciprocitythatIdiscusshere: thatbetweengovernmentandindividual. Reciprocitybetweengovernmentandindividual Whatweseeappearhere,istheconstitutionofanactive,disciplinarysubject. ThisisexactlyinlinewithwhatIdescribedinthepreviouschapter:oneof thewaysinwhichinnovationpolicysubjectivatescarerecipients,isbymak ingthemmonitortheconductofphysicians.Animportantquestioninthe 78

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lineofthediscussionthatIhaveaddedinthischapteriswhypeoplewould acceptsucharole. IncontrasttoFoucaultsworkonpanopticism,hefocuseslessoncen tralisedformsofsubjection.Inalecturein1980atDartmouthCollege,not longafterthelecturesthatIrefertoheremainly,heremarkedthat:WhenI wasstudyingasylums,prisons,andsoon,Iinsisted,Ithink,toomuchonthe techniquesofdomination(Foucault,1993,p.204).Instead,hebecameaware oftherelevanceofpracticesoftheself.Inthe1980lecture,hearguedthat,in contrasttosuchearlierworkondominationcentredgovernment,hewould liketostudygovernment[..]startingfromthetechniquesoftheself(1993, p.204).HislecturesthatconstituteTheBirthofBiopoliticsmayberegardedas afirststepinthisdirection.Foucaultargueshere,albeitsomewhatimplicitly, thatliberalgovernmenttakesplacethroughtheagencyofselfinterestedac tors.Subjectsare,asitwere,askedtoassumeadifferentrole.Unsurprisingly, thiswayofthinkinghasitsrootsinthesecondhalfofthe18thcentury.Fou caultarguedthatwhatwecallhomoconomicusstartedtoberegardedas thepartner,thevisvis,andthebasicelementofthenewgovernmentalrea sonformulatedintheeighteenthcentury(2008,p.271).Liberalgovernmen talityisnotreservedtostatepractices,butisactedoutbyindividualsubjects aswell.Subjectsare,inasense,selfproducing(Binkley,2009). ThenotionthatFoucaultuncoveredpracticesoftheselfdoesnotimply thathefindsnodisciplinarypowerinneoliberalsociety.Itisratherthatitis moredispersed.Somecommentatorshavearguedthatneoliberalismwould involveminimalstateinterference(McNay,2009).Iwouldarguethatthe pointisratherthatthefunctionofcontrolchanges,notthatitdiminishes.The distinctionbetweentwotypesofneoliberalismishelpfulinthisrespect(Peck &Tickell,2002).The1980sareoftencharacterisedbyarollbackofpublic institutions,whilethe1990sareknownforarolloutofnewneoliberalinsti tutions.ThelatterismoreinlinewithFoucaultslineofreasoning.Particu larlywithrespecttothewaythehomoconomicuswasregardedinclassical liberalismandneoliberalism,wecanseehowthethinkingaboutcontrol changed.Inthe18thcentury: Fromthepointofviewofatheoryofgovernment,homo conomicusisthepersonwhomustbeletalone.Withregardto homoconomicus,onemustlaisserfaire,heisthesubjectorobjectof laisezfaire.Andnow,inBeckers[neoliberal]definition[..]homo conomicus[..]appearspreciselyassomeonemanageable,someone whorespondssystematicallytosystematicmodificationartificially 79

Encoding neoliberal reciprocity. Connecting patient, government and society

introducedintotheenvironment.Homoconomicusissomeone whoiseminentlygovernable(2008,p.270). Iwouldarguethattheclassicalliberalpositionofspontaneoussynthesisis replacedbywhatwemaycallorchestratedsynthesisinneoliberalism.This willbecomeevenclearerwhenthisisconnectedtothefocusoncompetition. ForGermanneoliberalscompetitionisnottheresultofanaturalinterplayof appetites,instincts,behaviour,andsoon.Inreality,theeffectsofcompetition aredueonlytotheessencethatcharacterizesandconstitutesit(Foucault, 2008,p.120).Inotherwords:ifwewantpeopletocompete,wehavetomake them. Inasense,neoliberalgovernmentcanbecalledgoverningbyfreedom, albeitaratherparticular,economisedconceptionoffreedom.Foucaultarticu latedthismostclearlybysayingthat,inneoliberalism,controlisnolonger justthenecessarycounterweighttofreedom,asinthecaseofpanopticism:it becomesitsmainspring(2008,p.67).Foucaultsmainargumentseemstobe thatthepointofcontrolunderpanopticismwastoprotectsociety,orcertain (elite)groupsfromthedangersthatthefreedomofothersmayimpose(Fou cault,1978a).Thisisrelatedtomyearliercommentthattherewasstillanas sumptionthatthereweredomainsinwhichgovernmentcouldinterfere,and domainsinwhichitcouldnt.Underneoliberalismasapostpanopticalphi losophybycontrast,controlisneedednottoprohibitfreedom,butparticu larlytoassurefreedomofall,inthesenseoftheearliermentionedeconomic game.Bothwaysofthinkingassumeadvantagestotheexerciseofcontrol, butdifferentones.Oneofthecorefeaturesthatdistinguishes20thcentury formsofneoliberalismfromclassicalliberalismistheideathatfreedomisnot agiven.Thereisnoinvisiblehandthatwillleadmarketstoequilibrium. Therefore,laissezfairetypesofgovernancewillnotdo.Instead,whenitcomes tofreedom,governmentsneedtomanufactureitconstantly,toarouseitand produceit(Foucault,2008,p.65).Hestatesthat[l]iberalismmustproduce freedom,butthisveryactentailstheestablishmentoflimitations,controls, formsofcoercion,andobligationsrelyingonthreats,etcetera(2008,p.64). Whenitcomestothesubject,freedomshouldnotbeconsideredasa formofautonomy,assomeauthorsdo(McNay,2009),norisitantitheticalto (state)power(Patton,1989).Inneoliberalthought,thedistinctionbetween publicandprivate(Hamann,2009),andthecitizenandtheeconomicsub jectislost.Becausetheneoliberalsubjectisfundamentallystaged,thisform ofgovernmentalitynolongerhasanoutside(Read,2009).

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Ifthechallengeofneoliberalismisindeedtostageadisciplinarysubject, thequestionishowtomakeindividualsadoptsucharole.Afterall,neolib eralismisstillaparadigminwhichthefearofthestateiswidespread.How canthenotionsofanactivepolicytoshapeindividualsbecombinedwiththe principleofnotinterferingintheir(economic)livesdirectly?Howcangov ernmentsmonitorwhethersubjectsindeedassumetherolethattheyareex pectedtotake?Howcangovernmentssteer,whilereleasingdisciplineinthe senseofdirectlyinterferinginpeopleslives?Howtomakesurethatresis tancewillbelimited? ThelinethatIwanttohighlightincopingwiththisquestionisthe changeinthinkingabouttheapplicationofdisciplinarytechniques,againin thelightofreciprocity.Anearly,preneoliberal(17th18thcentury)exampleis whathecallstheparadoxofthepolice:Thepolice[..]iswhatenablesthe statetoincreaseitspowerandexertitsstrengthtothefull.Ontheother hand,thepolicehastokeepthecitizenshappyhappinessbeingunderstood assurvival,life,andimprovedliving(1979,p.251252).Twoaspectsareim portant:first,itwasstillacceptabletointerfereincitizenslivesdirectly,and second,statepowermayincreaseifitkeepscitizenshappy.Thepolicewas theretoprohibitthefreedomofsomeinfavourforthefreedomofothers.It wasmeanttocontrol(potentially)criminalelements. Thenotionthatneoliberalthinkingaboutreciprocityintheexertionof governmentalpowerhasclearlydepartedfromcontractbasedformscanbe seeninitsreactiontowhatFoucaultcallsthepactsofwarthatwerepro posedaroundWWII: pactsintermsofwhichgovernmentsbasicallytheEnglish,and toacertainextenttheAmericangovernmentsaidtopeoplewho hadjustbeenthroughaveryseriouseconomicandsocialcrisis: Nowweareaskingyoutogetyourselveskilled,butwepromise youthatwhenyouhavedonethis,youwillkeepyourjobsuntil theendofyourlives(2008,p.216). Neoliberalthinkersreactedstronglyagainstsuchsocialcontractualsetups thatwerethefoundationofpostwarwelfarestates.Foucaultfurtherdevel opstheexampleofsocialinsurancetoexplainhowthinkingaboutreciprocity instateinterventionhaschanged.Ratherthansayingthatsocietyasawhole isaskedtoprotectindividualsagainstrisks,asisthecaseinsocialistthought, hearguesthatneoliberalsclaimthat: 81

Encoding neoliberal reciprocity. Connecting patient, government and society

[s]ociety,orrathertheeconomy,willmerelybeaskedtoseetoit thateveryindividualhassufficientincometobeable,eitherdi rectlyandasanindividual,orthroughthecollectivemeansofmu tualbenefitorganizations,toinsurehimselfagainstexistingrisks (Foucault,2008,p.144). Thisreferstothemodeloftheindividualasaplayer,theprimarydecision makerofaneconomicgame,inwhichhefunctionsasamicroenterprise.The provisionofbasicsocialinsuranceisbasedontheideaofensuringthatno playerdropsoutofthegame,astomakesurethatthesettingsforcompeti tionremainintact.Foucaultclaimsthat,incontrasttosocialistconceptionsof socialsecurity,theneoliberalparadigmisnottoreducerelativepoverty i.e.tochangetherelativegapbetweendifferentincomesbutmereabso lutepoverty,belowacertainthreshold.Stateinterventionisnotregardedas theenforcementofanagreementbetweenindividualsandthepopulationto sustainprincipleslikeequality.Rather,itismeanttoenforcethebasic boundariesofeconomiclife,whichareexpectedtoenablereciprocity. MovingovertotheAmericanneoliberalismoftheChicagoschool,Fou caultstressesthestrategicprogrammingofindividualsactivity(Foucault, 2008,p.223).ThisreferstothehumancapitaltheorythatIdiscussedinthe previouschapteralready.Bystressingtheprojectionofindividualenrich ment,Americanneoliberalismjustifiesgovernmentalinterventionineduca tioninordertoargueforinvestmentinthehumancapitaloftheenterprise oftheself.Eventhoughthissignalsdirectinterventioninindividualslives, itshouldbearguedthatthisispresentedasamerechangeinboundarycon ditions.Itisquestionable,however,ifthereissuchathingasanon interveningcondition(Dix,2010).Consideringthefocusoninvestmentin thehumanenterprise,suchinterferenceofgovernmentsisaccepted.Citizens gettofurthertheirpersonalentrepreneurshipandgovernmentsreceivepro ductivityinreturn. ThelastpointIwanttostresshereisthechangeinthinkingaboutthe useofperceptioninapplyinggovernmentalpowerinthementionedrecipro calrelations.Foucaultsargumentisthatindividualsaremadetobelievethat theygetsomethinginreturnfortheirroleinsociety.First,inGermanOr doliberalism,therewasanattempttoconstructasetofwhatcouldbecalled warmmoralandculturalvalueswhicharepresentedpreciselyasantitheti caltothecoldmechanismsofcompetition(2008,p.242).Moreimportantly, Foucaultregardssecurityasacoreconcept(Tellmann,2009)inreferenceto perception,onethatwasturnedintoaprincipleofcalculation:[t]heproblem 82

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ofsecurityistheprotectionofthecollectiveinterestagainstindividualinter ests.Conversely,individualinterestshavetobeprotectedagainsteverything thatcouldbeseenasanencroachmentofthecollectiveinterest(Foucault, 2008,p.65).Heclaimsthatthereisamechanismtoconditionindividualsto continuouslyexperiencetheendangermentoftheirsecurityposition,which iswhathecallsacultureofdanger.Thisnotionofendangeredsecurityis usedinneoliberalismasajustificationforstateintervention.Byallowing governmenttoplayaroundwithboundaryconditions,youassureacertain levelofsecurityinyourlives. Possibilitiesofcriticismanditslimits Ifindividualautonomyisnottheoppositeoforlimittoneoliberalgovern ance,butratherliesattheheartofdisciplinarycontrolthroughresponsible selfmanagement,whatarethepossiblegroundsuponwhichpoliticalresis tancecanbebased?,asMcNay(2009,p.56)asksrightfully.Theoverviewof neoliberalthinkingonreciprocitythatwasgivenaboveisambiguous,inthe sensethatitisemphasised,ontheonehand,thatcitizensoughttoexperience benefitfromtheirrelationtothepopulationandtogovernment,butonthe otherhand,thatthisbenefitmightbeindirectandnonexclusive. Foucaultproceedstoshowtheliberalargumentforhowindividualsor thepopulationcanclaimtheirreciprocalrelation.Referringtotheinternal limitationofgovernment,Foucaultformulatestheneoliberaltheoremthata governmentthatignoresthislimitationwillnotbeanillegitimate,usurping government[aswasthecaseinthejudicialmodelWM],butsimplyaclumsy, inadequategovernmentthatdoesnotdotheproperthing(2008,p.10).This impliesthatcitizenswhowanttosecuretheirpositionshouldnolongerrefer totheirnaturalrights,buttothelawsofpoliticaleconomy,inordertoex plainthatgovernmenthasnotactedintheirinterest.Foucaultexplainsthis, albeitsomewhatcryptically,byreferringtothetypeofcriticismthathomo economicusmightemploy: Homoeconomicusissomeonewhocansaytothejuridicalsovereign [..]:Youmustnot.Buthedoesnotsay:Youmustnot,becauseI haverightsandyoumustnottouchthem.Thisiswhatthemanof rights,homojuridicus,says[..]Homoeconomicusdoesnotsaythis. Healsotellsthesovereign:Youmustnot.Butwhymusthenot? Youmustnotbecauseyoucannot.Andyoucannotinthesense 83

Encoding neoliberal reciprocity. Connecting patient, government and society

thatyouarepowerless.[..]Youcannotbecauseyoudonotknow, andyoudonotknowbecauseyoucannotknow[..][P]olitical economyhastoldthesovereign:Notevenyoucanknowthetotal ityoftheeconomicprocess.Thereisnosovereignineconomics. (Foucault,2008,p.282283). Whatismostinterestinginthisrespectisthatwehaveseenbeforethatciti zensarepurposefullykeptinthedarkaboutmacrolevelissues.Herewesee thattheyareexpectedtofunctionasaknowledgeablehomoeconomicuswhen itcomestotellinggovernmentswhatnottodo.And,equallyimportantly, governmentisalsolimitedinitspossibilitiestoknow,andprobablytoset boundaries.Nevertheless,onthebasisoftheabove,governmentsseemtobe inafavourablepositioncomparedtocitizens,whenitcomestogettinga grasponreality.Particularlywhenwekeepinmindthatsuchgovernments applymechanismsofperceptiontocreatewarmvaluesontheonehand,and acultureofdangerontheother,thereseemstobeagooddealofpurposeful ambiguityaroundtheneoliberalsubject,whichimpliescertainlimitstocriti calagency.ThisprovidesaninterestingreflectiononMckeesoptimistic statementthatsubjectsarereflexiveandcanaccommodate,adapt,contestor resisttopdownendeavourstogovernthemiftheysowish(2009b,p.479). Thequestionistowhatextentthisholdsinasituationthatischaracterisedby fundamentalasymmetries.

Theelectronichealthrecord2
WhatIhavetriedtounfoldinthefirstpartofthischapter,ishowsubjectiva tionoccursinanumberofexpectedreciprocalrelations.Oneaspectthatbe cameapparent,isthatthetwodistinctsubjecttypesthatIconcludedthe previouschapterwitharereconceptualisedintheserelations.Inasense, theyaregivenarationale.Ideasaboutreciprocityprovidesomesenseofan argumentationofwhypeopleareexpectedtoacceptsuchroles.However,I havetriedtoindicatetowhatextenttheroleofcontrolandperceptionplays apartinstagingthisacceptance.Intheremainderofthechapter,Iapply thiswayofthinkingtooneexampleofaDutchproinnovationpolicy:the creationofaninfrastructureforanationalelectronichealthrecord.
Part of this section is taken from an earlier publication (Mensink & Birrer, 2010), the remains of this text are published in chapter four of this thesis

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InformationtechnologyisgenerallyapopulartopicforaFoucauldian analysis(seee.g.Munro,2000;Henman&Adler,2003).Often,however,they focusexclusivelyonthepossibilitiesforsurveillancethatitoffers.Even thoughIbelievethistobeanimportantelement,inthiscase,Ishowthat technologycanalsoillustratequestionsofneoliberalsubjectivity,andmore specifically,reciprocity. Thefirstminister(liberaldemocrat)whostartedtheprocessofmoving towardsanationalelectronichealthrecordarguedtointendnottointerfere inthesectordirectly(MinisterievanVWS,1997),inproperneoliberalfashion. In1999,however,thisclaimwasfoundnotrealistic(TK,2000/2001a);hersuc cessor(conservativeliberal)subsequentlyproceededtosetoutclearlinesfor thedevelopmentofthisplatform.Still,theelectronichealthrecordisre gardedasaframeworkcondition,orinfrastructure,andparticularlyone thatissupposedtorearrangestreamsofinformation(seee.g.RVZ,1996; 1998a;2002a;MinisterievanVWS,1997;TK,2000/2001a;NICTIZ,2002a).The assumptionisthatunequalaccesstoinformationstandsinthewayoffree competition(RVZ,1996). TheideaofusingdatafromElectronicHealthRecordsgoesbacktothe mid1950s;sincethenithasgonethroughmanystagesofdevelopment.Bon nieKaplan(1995)hasshownhowmedicalcomputingwaslinkedtosubse quentpoliciestodevelopabasicresearchinfrastructure,toimprovetheac cesstoandqualityofcare,andtoachievecostcontainmentandprospective payments.Afterherarticle,however,ElectronicHealthRecordsentereda newstageofdevelopment,bybeingpositionedasatoolforintegrating(in ter)nationalhealthsystems. Inlinewithinternationaltrends,theDutchdebatearoundtheformation ofanElectronicHealthRecordwithnationalcoveragearosemid1990s.Main actorsinthisrespecthavebeenthesecondchamberofparliament(herere ferredtobytheDutchtermTweedeKamer(TK)),subsequentministersof healthcare,thePublicHealthCouncil(RVZ)andtheNationalITInstitutefor Healthcare(NICTIZ).Nonetheless,manymoreactorsmaybeidentified,in cludingstandardisationbodies,thestandardsthemselves,medicaljournals, numerousindividuals,researchers,researchinstitutes,consultancies,etc. Whererelevant,Iattempttohighlightwhoactedwhere.Thegoalofthispa perisnot,however,toperformaprocessstudyofthemannerinwhichthe EHRdiscoursehasunfolded. Beforestartingtheanalysis,afewmoreintroductoryremarksaboutthe wayIusethescriptconceptinthischapter.Inchaptertwo,Idiscussed scriptsinrelationtoartefactsthatweredevisedinordertomaterialisepar 85

Encoding neoliberal reciprocity. Connecting patient, government and society

ticularmeasurementsoftheproductivityofinnovation.WhatItriedtoshow isattemptsofpolicymakerstoinscribeaparticulartypeofdesiredbehav iourofdoctorsandpatientsintocertaintoolsandmethods.Inthischapter,I examinesimilarinscriptionattempts,butnowinrelationtoeffortstomake theelectronichealthrecordinfrastructuredosomething.Whatithastodo, istoenforceparticularrelationsofreciprocity.Thisapproachisrathercom montothestudyofelectronichealthrecordsandtechnicalinfrastructuresin general(Hanseth&Monteiro,1997;Hansethetal.,2006;Lee&Oh,2006;Sa hay,2003).AsIsaidintheintroductiontothischapter,thiswayofexamining inscriptionisonesidedindifferentrespects:itsuggestssocialdeterminism, thenotionofmaterialisingdiscourses,andstructuralistreadingsofinfra structures.Thereasonforadoptingthisapproachdespitethislackofsophis ticationisthatitisverysuitablefordescribingthetypeofthinkingthatis voicedinthepoliticaldocumentsthatconstitutetheelectronichealthrecord discussion.I.e.thesecriticismscouldbeappliedtotheviewsofnumerous stakeholdersthatareinvolved.Infollowingchapters,Iunpackthiswayof thinkingaboutinscriptionsandscripts.Fornow,however,amoresophisti catedviewwouldonlymakemattersmorecomplicated. Reciprocitybetweenindividuals Inthepreviouschapter,Ialreadyhighlightedthattherelationbetweendoc torandpatientisfundamentallyreassessedintheinnovationdiscussion.As wesaw,aprincipleagentrelationwasintroduced.OnthebasisoftheFou cauldiananglethatIunfoldedinthischapter,however,wecanimproveour understandingofthisrelation. FollowingtheFoucauldiananalysisofneoliberalism,wewouldregard bothcareprovidersandreceiversasentrepreneurs.Carereceiversinparticu larwouldberegardedasentrepreneursoftheself.Thepolicydiscussion aroundtheelectronichealthrecordneverusessuchaformulation.However, inthelineoftherolethatwesawbeingattributedtothepatientintheprevi ouschapter,suchapointofviewseemstomakesense.Thepatientisconsid eredapartyinthehealthcaremarket,maximisingitshealthadvantageat minimalcosts.Patientdemandissupposedtosetinmotionasenseofcrea tivedestructioninthesupplyofhealthcareservices.Innovativeproviders, offeringhighqualityproductsortreatments,areexpectedtobeselected.This wayofreasoningcanalsoberecognisedinthePublicHealthCouncilsFrom patienttoconsumerreport(RVZ,2003b).Nevertheless,wemustnotimaginea 86

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passiveconsumer,inthesenseofthetraditionalnotionofaproducerdriven consumersociety.Thefuturehealthcareconsumersaremoreentrepreneu rialthanthat. Intermsofthereciprocitydiscussion,thisevokestheimageofamutu allybeneficialrelationbetweenabuyerandasellerofaservice.Assaid,the stressisnolongeronassessingreciprocitybytheperceptionofthevalueof anobjectofexchange.Instead,thefocusisonthebenefitsthatarelationof competitionwouldimplyforbothparties.Forneoliberalism,however,itis notexpectedthatacompetitiveattitudeandpropercircumstanceforcompe titioncomenaturally.Thestateneedstocreateaframeworkwithinwhich thiscanoccur. Incaseoftheelectronichealthrecord,theprimemotivatoristoattempt tobalanceouttheinformationasymmetrybetweendoctorandpatient.Even thoughtheEHRdiscussionwasrestrictiveatfirst,whenitcametotheaccess ofthepatienttohis/herrecord.Thisgraduallychangedoverthepastdecade, however,largelyduetotheadvocacyofthePublicHealthCouncil.Fornow, careprovidersareregardedtohavetoomuchpowerovertheircarerecipi ents.Thismakesithardforpatientstofurthertheirhealthentrepreneur ship.Thenotionoftheentrepreneuroftheselfisstronglyechoedinthe wayhealthconsumersaredescribedasmanagersoftheirownhealth,and theirownhealthinformation.Ifweconsiderthisfromthepointofviewof thescriptoftheelectronichealthrecord,wehavetoimaginethattherecord isprogrammedinsuchawaythattheadditionalinformationthatitwill makeavailablewilltriggeradifferenttypeofpatientbehaviour.Thisevokes theimageoftheprincipalsubjectthatIoutlinedbefore.However,nowthat weimaginethepatientinareciprocalrelationwithhis/hercareprovider,this picturegainsnuance.I.e.wehavetoimaginethatbothpatientanddoctor gainfromtheirpositionasrespectivelyprincipalandagent.Bytheaddition oftheelectronichealthrecord,thebalanceofpowerisexpectedtoshift. Reciprocitybetweenindividualandpopulation Fromthemid1990sonward,differenttopicalmacroproblemshavedomi natedthediscourseonthenecessityofrestructuration,rangingfromwaiting lists(RVZ,1996)andwaitingtimesforgettingmedicaltreatmentinthe1990s (TK,2000/2001a),tothethreatoftheageingpopulation(Scheepbouwer,2006) andmedicalmistakesasaresultofpoorinformationexchangeintheprevi ousdecade(NICTIZ,2003;TNSNIPO,2003;2004a;MinisterievanVWS,2005e). 87

Encoding neoliberal reciprocity. Connecting patient, government and society

Costreductionseemstobetheprimechallenge(TK,1995/1996;RVZ,1996; 1998a;TNSNIPO,2004a),whichisalsoechoedinacademicstudies(Walkeret al.,2005). Thereisastrongbeliefintheimpactofentrepreneurialinteractionsbe tweendoctorsandpatientsonissuesatthelevelofpublichealth,asitisar guedinareportthatadvocatesentrepreneurialconsumerismforpatients (RVZ,2003a).Weshouldkeepinmindthatthisislargelybasedontheexpec tationofdifferentscripts.Inthepreviouschapter,Ipointedattheinscrip tionofmeasurementtools.Withrespecttothedoctorpatientrelation,the notionoffunctionorienteddescriptionturnedouttobethemostrelevant. Inthischapter,weseeasimilarexpectationoftheelectronichealthrecord. InanadvicetogovernmentbythePublicHealthCouncil,entitledBe tweenmarketandgovernment(RVZ,1998b),thecounciladdressestheparadox ofthepatientssituation:Thetensionbetweenautonomyanddependency, betweenindividualandgeneralinterestistranslatedasatensionbetween marketandsupplyregulation(RVZ,1998b,p.3).Thepatientasacriticalcon sumerwasconsideredthemostpromisingscenariotoaddressmacrolevel issues.Thisrelianceonindividualintereststosolvemacrolevelissuesrecalls themannerinwhichcollectiveissuesarethoughttobesolvedbymeansof anorchestratedsynthesis.Allthatisneededistosettheframeworkpa rametersright:onthebasisofinscribingtransparencyandtherightinforma tion,healthconsumerswillholdtheirdoctorsaccountableforbadwork(RVZ, 2003a),andwillrationallyselectinsurancesorhospitalsthatofferthebest packageintermsofcostandquality(RVZ,1998a).Doctorswillbemoreinno vative,andmoresuccessfulbecauseofthis.Similarexpectationsareac knowledgedinternationallyaswell(Gregory,2000a). ThePublicHealthCouncilnotedthattherecordcouldbeusedtocalcu latethechancethatpatientssufferfromparticularillnesses,whichcouldin turnbeusedforcalculatingthecosteffectivenessofparticulartreatments (RVZ,2001).ThenotionthatanEHRsystemcouldbeusedforsomethingim pliesthatnoconcretescriptshavebeendevelopedforthis.Wecouldimag ine,however,thattheremightbesoftwarepackagesthatprobedoctorsto performthesetypesofmeasurements. ThesamereportmentionstheearliermentionedQualityAdjustedLife Years(QALY)calculation.Asimilarcalculativemindsetcanberecognisedina reportonthefinancialcostsofmedicalinformationmistakesforsociety(TNS NIPO,2004a).Thehealthrecordispositionedasatooltoprohibitsuchcosts. Theinscriptionthattakesplacehereisverybasic:bymakingdoctorsuse computers,sloppyhandwritingisomitted.Paperbasedandelectronichealth 88

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recordsarebothtechnologies,butwithdifferentscripts.Papermakesdoctors useapen,whereascomputersmakethemusethekeyboard.Thismaysound trivial,butclearly,theexpectationsofthischangeinscriptareconsiderable. Here,wehearechoesoftheothersubjecttypethatIoutlinedbefore,the humancapitalsubject.Thelogicisthatbyinvestinginanelectronichealth record,andprohibitingmedicalmistakes,weinvestinpeople.Thiswasthe logicthatIunfoldedinthepreviouschapter.Giventheadditionalframework ofreciprocity,however,wemaywonderwhatbenefitsindividualsmayre ceivefromcivilsocietyinreturnforthenewrolethattheyareexpectedto adopt.Thebasiclogicseemstobethatindividualswillalsobenefitfrom solvingmacrolevelproblems:theywouldntneedtowaitfortreatmentas long,theywouldbewarnedearlieraboutepidemics,etc. Reciprocityinbetweengovernmentandcivilsociety Thenotionoffocusingonmacrolevelproblemsisstronglyrelatedtoacon ceptionofgoverningcivilsociety.TheEHRinfrastructuredoesmorethan merelyconnectingpatientsanddoctors.Itisalsoatoolforinstitutionsthat governhealthcare.ThePublicHealthCouncilarguethat[t]heprimarygoal ofthepatientrecordisthesupportincareprovisiontotheindividualpatient. Apartfromthat,itcanserveforinformingthepatient,monitoringquality, businesscoordination,managementsupport,researchandstatisticsandedu cationandpolicy(1996,p.70).Thecouncilproposestousetherecordto produceultimatestrategicmanagementinformation.Theuseofsuchdata forpolicymakingpurposesisgenerallyacknowledged(Henman&Adler, 2003;Jonesetal.,2005).Macrolevelapplicationsthathavebeendistin guishedoverthepastdecadeare:thesignallingofepidemicsandlargescale poisoning(TK,2000/2001a),automatedadministration(TK,2007/2008b), benchmarkingofthequalityofcare,scientificresearch,decisionsupport (RVZ,2005b),replacinghumanlabour(RVZ,2002b),increasedlabourproduc tivity(MinisterievanVWS,2007a),transferringhealthcaretaskstothepatient (RVZ,2002a),automatedcostcalculationsandagenerallyhealthierpopula tionandlabourmarket(TNSNIPO,2004a).Suchexpectationsarealsorecog nisedintheliterature(seee.g.Gregory,2000a).Oncedataismadeanony mous,patientprivacyisthoughttobeanissuenolonger,allowinginforma tiontobereusedforbroaderpurposes.Generally,theymakefairlyclearthat individualinterests,suchasprivacyprotection,shouldnotoutweighgeneral

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interests,therebyrelatingexactlytowhatFoucaulthasnamedtheproblem ofsecurity(Foucault,2008,p.65). Whileindividualspatientsareneededtocompilethedataforaddress ingpopulationlevelproblems,thesameistruetheotherwayaroundaswell. Largedatasetsaresuggestedtobeusedtoinfluencepatientslives.The councilreferstothecapabilityofintelligentsystemstorecognisepatternsin massivedatasets,whichcanbeappliedtocalculateaverages,andtoset norms(RVZ,1996;2005b).Thesenormscanbeusedinphysiciansdecision supportsystems,togiveanautomaticsignalifameasurementexceedssuch norms. Thisbringsthediscussiontothequestionofhowtosetupthisnew frameworkforinformationprovisionexactly.Here,itislikelythatconcrete scriptsareimagined.Theformulationisnotyetveryprecise,buttheconcep tionseemstobetodevelopsystemsinsuchawaythattheymakemedical professionalsgatherdatainaparticularmanner.Firstofall,thecouncil pointsoutthatcertainmeasuresarerequiredtoenablepopulationlevelap plicationsontopofindividualones,mainlywhenitcomestodataprocess ing.Whattheyrefertoasclassicobtainingofdataputtinginorder,se lecting,presenting,etc.(RVZ,1996,p.12)isconsideredinadequateforthis purpose.Afutureproofsystemshouldbecapableofdatainterpretation, whichconcernsissueslikeknowledgesystems,patternrecognition,etc. Theystressthat,[u]ptorecently,datainterpretationwasreservedforhu manintellectualcapacities.Newtechnologiesenablethatalsoinformation systems,beittoarestrictedextent,areabletodothis(RVZ,1996,p.12).Basi cally,theyargueforstructuredinputofdata,i.e.notmakinguseoffreetext fields,inordertoallowforcomputerisedanalysis.Eventhoughthethen ministeracknowledgedtheneedforfreetextfieldsforcapturingtherichness ofthemedicalcontext,hearguedforgreaterobjectivitythroughstructured input(TK,2004/2005b).Thisdiscussionisstillanissueintheongoingstan dardswarbetweentwocampsthateachfavouradifferentapproachto managingdatastorageandexchangebetweenpartsofthesystem(Eichelberg etal.,2005).Thiswilllargelybethepracticalangleforthenextchapter.The suggestionofstructuringinformationrelatestotheglobalizingandquantita tivetypeofknowledgethatFoucault(1982)describesasanecessityforgov erningpopulations.Ontheindividuallevel,thepublichealthcouncilpro posesthestorageofinformationintherangeofeverythingfromdiagnostic acts,suchasthemakingofarntgenphoto,uptoapatientsmeal(RVZ, 1996,p.86).TheinstitutethatissupposedtopreparetheDutchelectronic healthrecordhasproposedtostorepatientinformationinnaturallanguage, 90

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andtotranslatethistocodeddataforsecondaryuse(NICTIZ,2002a).Whatis notyetclear,however,ishowthisistobeimplemented.Ontheonehand, governmentscouldsimplycreaterulesthattellmedicalstaffwhichdatais needed.However,itisalsopossiblethatsoftwaresystemswouldbede signedinsuchawaythatitisthetechnologiesthatmakethemdotheir workinaparticularway.Wecouldimaginethatadoctorcouldnotmoveon tothenextscreenofhis/herEHRapplication,beforecompletingallrequired datafields. Secondly,thequestionofhowtoexchangedataisarelevantpoint.From themid1990sonward,theideaofapersonalchipcardthatwouldcarry medicaldatawasaseriousoption.However,thePublicHealthCouncilar guedthat: Inusingapatientmanagedchipcard,differentdatacanonlybe linkedonthebasisofpatientapproval(intheformofphysical presenceofachipcard).Thisisofgreatimportanceforpatientpri vacy,butforanonimisedepidemiologicalresearchthisisamajor restriction,whichcandamagegeneralinterests(RVZ,1996,p.84). Anelectronichealthrecordwithnationalcoveragewouldnothavethese shortcomings. Third,thereisthequestionofwhattheproperunitistoconnectdata to.Alsohere,thePublicHealthCounciladvicesanindividualisedsetupina collectivearrangement:ratherthanstoringdatainrelationtomedicalacts, datashouldbeconnectedtothepatientas(s)heistheonlyconstantfactor (RVZ,2005b,p.5).Practically,thismeanstoconnectmedicaldatatotheso calledCitizenServiceNumber,whichwaspreviouslyjudgedtobeinade quatefromthepointofviewofprivacyandfraud. Reciprocitybetweengovernmentandindividual Theinformationalletterandbrochurethatweresenttoalladultcitizensin November2008providesaninterestingillustrationofFoucaultsthinkingon governmentaltechniquestostagetheneoliberalpatient.Imentionanumber ofaspectsparticularly:(i)thebrochuredoesnotprovideanyinformationon thecollectivegoalsoftherecord,justonafewadvantagesforindividualpa tients,(ii)thebrochureconveysthewarmtypeofvaluesthatFoucaultrefers towhendiscussingGermanOrdoliberalism(Foucault,2008,p.242):using 91

Encoding neoliberal reciprocity. Connecting patient, government and society

thevisuallyillustratedexampleofatypi calDutchwoman,withatypicalmedical issue,thereaderisshownabrightimage ofherfuturewiththerecord,(iii)themes sagestressesthatattentionwaspaidto issuesthatmightprohibitpersonalfree dom,suchassafety,easeofuseandsecu rity,(iv)thebrochureappealstothefeel ingofthreatenedsecurityintermsofthe riskofmedicalerrors,whichcouldbe overcomebyusingtherecord.Alsothe brochureseemstohavebeeninscribed. Thiscommunicationshowsanattemptto constructaparticularperceptionthat shouldbeseeninthelightofareciprocal powerrelation:citizensareaskedtotrust theirdatatobeprocessedelectronically,inreturnforageneralfeelingofse curityabouttheirpersonalhealth. Thelimitstothecriticalpatient Thisbringsmetoafinalpoint:Theletterofferscitizensthepossibilityofde nyingtheelectronicprocessingoftheirhealthinformation.Thisbringsus backtotheambiguouspositionconcerningthetypeofcriticismthatneolib eralsubjectsmaydeploy.Howshouldweinterpretthepossibilitytorefuse stateinterferenceinthelightofthiscase,however?Firstofall,citizensare givenanoptoutoption:theyareallowedtorefusetheuseoftheirdata,in steadofbeingaskedtoconfirmthis(optin).Itisknownthatthisapproach lowersthedegreeofrefusal.UptoMarch2009,438.000citizenshadinfact refused(NRCHandelsblad,2010).Secondly,becauseofthecreationofpercep tions,theinformationthatisprovidedtocitizenstouseasabasisforpossible criticismislimited.Athird,andmoreimportantelementthatIwouldliketo raise,however,isthatthelettertocitizenscouldberegardedasarequestto legitimisetheintroductionofanewframeworkforhealthcare.Despitethe seriousmacrolevelimplications,therequestismadetoindividuals,whichis inlinewiththeassumptionsofneoliberalthought.Becauseoftheinforma tionasymmetrybetweengovernmentandthesecitizens,however,individu

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alsareaskedtocommittoanimplicitreciprocalrelationshipwiththepopu lationofwhichtheyarepart. Governmentalityscholarsproposetofocusonstrategiesofresistance (Mckee,2009b),butthesehavebeenvirtuallynonexistentintheelectronic healthrecordcase.Theonlyrelevantexceptionperhapsisagroupof800 concernedgeneralpractitioners(CommitteeWakeUp)that,amongstother actions,participatedinexpertmeetingsorganisedbytheDutchsenate (Mckee,2009a).This,however,didnotleadtoanyformsofresistancebyciti zens.

Discussionandconclusions
WeleftPart1withanunderstandingthatreframinghealthcarepolicyfrom thepointofviewofinnovationimpliesatwofoldsubjectivationofthecare receiver.Ontheonehand,(s)heisgiventheroleofprincipal,whicheffec tivelyimpliestomonitortheproductivityofcareproviders.Ontheother hand,(s)heissubjecttoinvestmentinhumancapital,beinggivenarolein societalproductivity.Itriedtoshowthatthesedifferentrolesofthecarere ceiverareexpectedtobeevocablebythescriptsthataregiventoparticular measuringtoolsanddescriptionsystems.Toputitsimply:theyareexpected tomakepeopledosomethinginaparticularway. Apracticallessonofthischapterasthatboththesamelogicofreasoning andthesamesubjecttypescanberecognisedinthediscussionaboutplan ninganelectronichealthrecordinfrastructure,asinthegeneraldiscussion aboutinnovationinhealthcare.AlsotheEHRisexpectedtocarrycertain scriptsthatwouldchangebehaviourofhealthcareactors.Firstofall,giving moreinformationtopatientisexpectedtochangetheirbehaviourvisvis theircareproviders.Thisaddsuptotheroleofthepatientasaprincipal subject.Secondly,thefactthathealthrecordkeepingwillbedonewitha differenttechnologycomputersinsteadofpaperalsoimpliesachangeof scripts.Makingdoctorsusecomputersisamaterialwayofsaying:youare nolongerallowedtouseyoursloppyhandwriting.Thereareotherdigital scriptsthatareexpectedtocontributetoovercomingmedicalmistakes, whichIwillnotdiscusshere.Thepointisthatsuchscriptsareexpectedto keeppatientshealthierand,therefore,moreproductive.Thisway,theelec tronicalsocontributestoconstitutingcarereceiversassubjectsofproductiv ity,orashumancapitalsubjects,asIcalleditbefore.InreferencetoFou caultsremarksontheneoliberaltheoryofhumancapitalinvestment,Ican 93

Encoding neoliberal reciprocity. Connecting patient, government and society

againremarkthatinnovationisconsideredasaninputforproductivityin crease,ratherthanasanoutput.Byinvestinginatechnologicalinfrastruc ture,governmentexpectsthehealthcaresectortoadoptmoreinnovations, whichwillreducemedicalmistakesandmakethepopulationhealthier. ThetheoreticalanglethatIintroducedhere,however,allowsustogo beyondtheunderstandingthatIunfoldedafterPart1.Thecaseoftheelec tronichealthrecordisnotjustimportanttoshowthatthesameprinciples applyasinthegeneraldiscussiononinnovationinhealthcarepolitics.Ihave triedtomaketwotheoreticaladvancesinthischapter.Firstofall,Ibroad enedFoucaultssecondmodeofsubjectivationfromtherathernarrownotion ofdividingpracticestotheideaofsubjectivationinpowerrelations.Thisis notabigstepcomparedtochapterone,inwhichpowerrelationsbetween doctorsandpatientswerealreadyimplied.Byprovidingasystematicover viewofFoucaultsscatteredremarksonreciprocityinpoliticaltheory,how ever,thisanalysisgainssubstance. Ihavetriedtoshowthatthedifferentrelationsofreciprocitybetween individuals,populationandgovernmentformaframeworkfromwhichthe basicsubjecttypesthatwereidentifiedinPart1canbebetterunderstood.To startwiththemostpractical:neoliberalthinkersexpectthatconstitutingcare receiversasprincipalsubjectandashumancapitalsubjectplacesthemin reciprocalrelations,respectivelywithcareprovidersandtheentirepopula tion.Withrespecttotheformer:bothpatientanddoctorareexpectedto benefitfromtheentrepreneurialattitudethatisattributedtothem.Inthelat terrelation,thereciprocitythatisexpectedtoariseismostlyindirect,inthe sensethatitcannotalwaysbetracedtoaparticularrelationofcompetitive exchange.Theindividualandthepopulationcannotexchangedirectly.The generallogicseemstobethattheindividualalsobenefitsfromtackling populationlevelproblems,bymeansofthedatathattheyprovide.Avery specificexampleofamutuallybeneficialindividualpopulationrelationin theeyesofneoliberalpoliticiansistheprocessingofdataforhealthcare norms.Individualdataisneededforgeneratinginformationabouthealth population(s).Viceversa,suchgenericinformationisexpectedtobeusable asinputforautomateddecisionsupportonindividualpatients. Lookingatreciprocityinmoregeneralterms,however,impliesthatthe subjectivityofthecarereceiverisshapedbyanumberofrelations.Suddenly, apatientisnotjusttheprincipalofhis/herdoctorandacoginthewheelof theeconomy.Inaddition,(s)heisalsoacompetitivehealthentrepreneur,a memberofcivilsociety,andcitizenoftheDutchstate.Whatismore,(s)he isexpectedtobenefitfromalltherelationsthatthesesubjecttypesimply. 94

Blueprintingpowerrelations.PlanningtheElectronicHealthRecord

Neoliberalismprovidesaframeworktoreconsiderthesubjectivityofthepa tient.Yes,thetwofoldsubjectivationthatappearedinPart1stillapplies,but itisnowembeddedinabroaderconstructthatwemaycalltheneoliberal subject.Forsubsequentchapter,therefore,Ishallusethisnotionasmypoint oforientation.Inneoliberalism,thepatientisconsideredasanoverarching entitythatcombinesanumberofroles.Theparticularrolethatthesubject actsoutdependsontherelationinwhich(s)heisengaged.Theserelations overlap.Thesubjectisdifferentandthesame,atanygiventime. Governmentsapplydifferenttechniquestoassurethatsubjectsdoin deedassumetheseroles,withoutinterferingintheirlivesdirectly.Thespon taneoussynthesisthatclassicalliberalsexpectedtooccurwastransformed byorchestratedsynthesis.Oneoftheimplicationsofthisorchestrationis thatpeoplearenotnecessarilyawareofthedifferentwaysinwhichtheyare subjectified.ManyoftherelationsthatIdiscussedherearesideeffectsof individualrelationsinwhichthecarereceiverengages.Thisisalsoimportant fromthepointofviewofresistance.Eventhoughtheneoliberalsubjectis consideredcapableofcriticism,thisisrestrictedbyinformationasymmetries. Assuch,individualsmightvoicecriticisminrelationtotheirindividual cases,butareunlikelytodosoinrelationtopopulationlevelissuesofwhich theyareunaware.Thisideacontradictswhatsomecommentatorsassume (seee.g.Mckee,2009b):theneoliberalsubjectmaybefreetosayno,butis unlikelytodoso,giventheway(s)heisconstituted.Thisappliestobothin dividualandcollectiveformsofresistance(McNay,2009;Read,2009).Indi vidualsareaskedtocommittoapolicyinstrument,ofwhichtheyareinca pableofjudgingmanyofitsparameters,mainlythoserelatingtomacrolevel goals.

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