Draft version. Please do not quote.

Medicine and Biological Citizenship

By Hernán Cuevas Valenzuela

Universidad Diego Portales
Escuela de Ciencia Política
hernan.cuevas@udp.cl
May 2009

1. Introduction

Nikolas Rose and Carlos Novas (2004) state that a new kind of citizenship is taking
shape in the era of biomedicine: biological citizenship. This is, because “aspects of
life once placed on the side of fate become subjects of deliberation and decision”
and “a new space of hope and fear is being established around genetic and
somatic individuality” (Rose and Novas 2004: 458). In his most recent book,
Nikolas Rose amends his previous notion of biological citizenship based on a
genetic and somatic individuality, to accommodate to an expanded notion that
makes it extensive to wider biological social marks of identity.

The concept of biological citizenship emphasizes the “biological conception of a

shared identity” and links “the conceptions of citizens to beliefs about the biological
existence of human beings as individuals, as families and lineages, as
communities, as population and races, and as a species” (Rose and Novas 2004:
440). This concept seems suggestive because it stresses the self-governing
practices of patients and their refusal to accept their identity as “sick persons” and
disease as “fate”. However, the concept remains an undertheorised category. Here
I put forward a notion of biological citizenship that refers to an emerging dimension
of citizenship and to a process of citizenship formation.

Towards the end it will become clear that my main statement is that biological
citizenship is a new form of political identity that empowers people, entitles them to
claim politically new rights related to the field of biopower, fosters self-care
practices and promotes practices of self-government through an innovative
articulation of medical knowledge and activists’ political practice that produces a
new political identity.

As it is known, Foucault used the term biopolitics to refer to the government and
control of populations through an array of strategies and devices that expand the
power over life. This exercise of power over life is what Foucault called biopower.
Foucault thought the aim of biopolitics was to both increase the productivity of the
human body and to discipline it as docile for the former purpose. Thus, an
important aspect of biopower that one should bare in mind is that it acts upon

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human life, public health and population’s existence, reproduction and decay with a
rationale, seeking the fulfilment of certain aims and purposes. Therefore, the
exercise of biopower cannot be neutral. But, can bioipower be excercised in a
different direction, not for biopolitical purposes? In this paper I claim that the
emergence of biological citizenship occurs within a new configuration of
power/knowledge in the realm of biopower that makes possible to imagine such
possibilities through the work of patient organizations. The structure of the paper is
as follows.

The second section of this paper deals with the problem of the relation between
medicine, the sick and the social system. In my opinion, Parsons functionalist
account of this relation prepares many of Foucault’s critical insights. Both authors
seem especially concerned with addressing the rationalisation of modern society.
In section 3, inspired by Foucault's studies, I present some of the key dimensions
of medicine that have to be taken into consideration for elaborating an outline of a
theory of the biological citizenship.

Following from the previous, the concluding section presents a concept of

biological citizenship conceived as a social and political practice and a process of
identity-formation; as a political category which is at a time universal and
differentiated; as conflict and society-centred (vs. state-centred); as anti-
essentialist (vs. essentialist)<, as promotional (vs. guarantee-centred); and as
intimate (vs. public).

2. Medical Knowledge and Social Power 1: Citizenship and Talcott Parsons’

Theory of the Sick Role

As it is well known, Talcott Parsons’ functionalist sociology (1951) developed the

idea that individuals occupy positions –what he called roles- within social structures
or institutions in the social system. Individuals need to accomplish their own tasks
and structures or institutions their own functions for the sake of the systems’ self-
preservation. The conservation of the system is what drives society. Thus, one
important feature of the social system is that it permanently seeks to enforce social
order. This imperative of self-preservation requires the socialisation of agreed
shared norms and values. And, consequently, all forms of deviant behaviour, such
as malingering, political anomie or crime, are regarded as obstacles for the right
functioning of the system. In a few lines I will come back to this in order to show
how illness is a particular form of deviant behaviour. This is important because the
biggest contribution of Parsons to the field of health and illness studies was the
concept of the sick role, through which the social dimensions of illness were made
apparent in his social theory.

Let me move now to the issue of citizenship and how it fits into Parsons
functionalist account. Following Crossley (2001), I take citizenship to accommodate
well to system theory. First, because the citizen can be seen as playing a key role
within the political system. As a tax payer, the citizen finances the state. As a voter

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s/he reproduces and legitimises the system through the selection of authorities,
allocation of preferences and expression of loyalties. As a recipient of welfare, the
citizen benefits from public and social policies, such as public health provision. The
citizen integrates all these dimensions. And, as I will show, it is this usually
overlooked dimension of the citizen as recipient of welfare what ultimately
legitimises the sick role. Let me show how do I see this link between citizenship
and the sick role in more detail.

As I have suggested earlier, from the functionalist perspective illness is conceived

as a form of dysfunction. However, not because it contravenes moral values but
because of obstaculising individual’s normal activities and especially putting him off
work. Illness is undesirable for both the individual and the social system because it
disrupts his/her normal role, deviating from his/her tasks and duties and also from
social expectations. The ill individual who is off work is a case of deviance calling
for normalization. S/he is not producing, s/he is not consuming and, in sum, is not
taking part in the basic exchanges of money that reproduce economic life.
Therefore, s/he becomes a deviant.

However, when we are sick we have no apparent responsibility for our impeding
condition. Why should we be targeted by all sort of recriminations and feel
ashamed because of being off work? Parsons as a good observer saw that when
off work because of sickness we ask for a particular permission: an experts’
certificate which must be provided by the right medical authority. This certificate
provides the ill with temporal legitimacy.

Parsons referred to the socially accepted ill as occupying the sick role, which he
conceived as a temporal situation that legitimises not being functional and
productive for a limited period of time. The patient can get psychological comfort
from the sick role because he becomes a centre of attention for the health care
system and his immediate social environment of relatives and significant others.
This account fits with our idea of the citizen as bearer of certain rights. Among
them, a right to demand health care. However, the individual who is acting the sick
role has to bare in mind that to legitimate his/her sick role he has to comply with
certain duties: a) he needs to recognise his/her condition; b) ask the legitimate
authority –medical authority in this case- to identify the illness (exercise of
diagnosis); c) show will to recover from his/her condition; for which d) he/she has to
follow obediently the physicians directions in order to re-integrate to his/her normal
functions as soon as possible.

Let me ask now: what is the role of medicine in all this? Its aim goes well beyond
healing and putting an end to individual’s discomfort. In this view, the key function
of the health care system and medicine is to help maintain the re-integration of
individuals into society. Or, put it differently, it is to re-establish to the body and
mind its functions so that the individual can fulfil his social tasks again. This
account fits well with the common sense representation of the good citizen:
someone responsible and who accomplishes his/her duties in a society where
productivity is valued.

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To sum up what has been stated until now, medicine and health-care systems
provide institutional legitimation of the sick role as a form of social deviance
through the physicians certification of the illness because the ill cannot be held
responsible for his/her condition. This is what distinguishes the deviant sick from
the deviant criminal (the latter can be held responsible for his actions).
Nonetheless, at the same time medicine and health institutions provide an
important social control. As Bryan S. Turner has pointed out, another function of
medicine is that it plays a crucial role as specialised arbiter or gatekeeper because
it secures society –especially its economy- from the disaster of mass malingering.
Thus, medicine not only restores health, but also has a normalizing and quasi legal
function. I will come back to this point when assessing Foucault’s contribution to
the study of medicine from the perspective of a surveillance society.

Patients and Doctors

To understand the power of medicine it seems important to look at the different

roles of the patient and the doctor. Turner (1995) suggests that uncertainty is at the
core of the medical paradigm and crucially shapes the representation of western
medicine and its characteristic doctor-patient relation. Patients’ ignorance on health
matters and trust on the physicians’ expert judgement is the quintessential feature
of medicine and of the patient-doctor relationship.

Because of patient’s ignorance, the patient is not in a position to judge the

effectiveness of the service against other forms of treatment. (…) [T]he
physician defines the clinical situation and controls the evaluation of the
product. It is this uncertainty which underlies the notion of the docile patient
role in relation to the doctor’s intervention. (…) [U]ncertainty is an essential
component of patient compliance within the sick role … [and] has little
control over the norms of treatment in terms of length, form and outcome of
the service. (194).1

The hierarchy introduced by scientific knowledge and the certification of the doctor
as a professional seem to be crucial. However, it is precisely here where the
dimension of rights of citizenship can be raised against the biomedical paradigm,
which I think is implicitly supported by Parsons theory. For instance, a strong
project of health rights can be mobilised against medicalisation of society2, the
1
On top of the previous point, theories of the professions have emphasised the process by which
“the medical profession became united into a single, recognizable profession, and how members
of this profession were able to upgrade their collective status, achieving recognition from both
governments and the public for their claims to expertise.” (Immergut, 2001: 16483, see also
Immergut, 2006, ch. 2 and Turner, 1995).

2
The medicalisation of society thesis sustains that ever wider spheres and processes of human
life and more and more social problems begin to be the object of medical inquiry and treatment.
This critical concept has led some medical sociologists to propose that there is a transformation
of ‘badness’ into ‘sickness’ (Conrad & Schneider, 1980, cited in Bury & Gabe (2004) p. 3)

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empowerment of patients/users vis-a-vis experts’ knowledge through mechanisms
of accountability, the application of the principle of informed consent in medical
treatment, the re-conceptualization of the patient as active user of health services
and his empowerment as an experience-based expert in his own condition.

It is the salience of this knowledge dimension what leads me to consider the work
of Michel Foucault. But also, I think that his view nicely supplements some of the
important insights of Parsons sociology of medicine. Let me begin by the criticisms
levelled against Parsons ideas.

The functionalist view of society tended to make universal claims, overlooking

historical particularities. Historical studies show that the notion of illness and the
position occupied by the ill in society cannot be universalised. Culture differences,
chance, complexity and contingency play a role in the formation of what is
understood as sickness and the ill at each point of history (Armstrong, 1983;
Foucault, 1965). Secondly, Parsons’ did not pay attention to the variety of ill neither
to different sorts of conditions. Among the latter, chronic illness and forms of
disability deserve special attention. In these cases, the “sick” might never fully
recover or might never be at the height of social expectations (Altman, 2001;
Green, 2009). Thirdly, the whole notion of the sick role is based on an underlying
consensus between the physician and the ill about his/her condition. However, in
some cases such consensus might not be reached, as is the case of resistant
‘patients’ who do not regard themselves as ill or disabled. The figure that
dominated in the sick role account is that of the passive patient. However, recent
events show the ascension of the empowered citizen who demands health rights
and/or who fights for recognition. The existence and multiplication of radical health
social movements that oppose medicalisation and medical knowledge in fields
such as metal health (Speed, 2002; 2006) and deafness (Blume, 2000; Sparrow,
2005) are good examples of the shortcomings of a theory based on the ‘passive
patient’ figure. On top of the previous, the reformation of health care services under
the neoliberal rationing principle of effectiveness plus the promotion of the active
consumer model have had enormous impact. Not only contributing to the
empowerment of ‘patients’ who demand for better services, but also on the
introduction of the principle of responsabilisation of the service user for his/her
own health. Individuals choice and competition between and within health
institutions are now driving principles in contemporary health care systems.
Fourthly, in differentiated modern societies driven by productivity and activity,
welfare is frequently seen as the counterpart of individual contribution to the
community through taxes, military service, political participation in terms of voting,
etc.-. The citizen’s entitlement to rights is balanced with his/her duties and
obligations to the state and the community of which s/he is part of. Therefore, the
chronically ill, the disabled or anyone who cannot or does not contribute to the
welfare but benefits from it is frequently stigmatised as someone who ilegitimatly
extracts resources. Fifthly, Parsons’ account of the sick role does not offer tools for
thinking about the experience of the embodiment of human beings and human
vulnerability and frailty (Turner, 2009). And finally, Parsons’ theory tends to
legitimise the biomedical paradigm representing medicine as unproblematic and,

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furthermore, as positive because it favours the social systems’ reproduction and
conservation. Somehow, this also misrepresents medicine and the doctor-patient
relationship (Turner, 1995).

Although the differences between Parson’s sociology of health and Michel

Foucault’s critical analytics of power as applied to health matters are enormous,
some continuities exist and justify analysing them together in this paper. Indeed,
both approaches stress that medicine and health institutions work as social control
devices. Second, they also share that medicine and health institutions constitute
forms of power that work on individuals and populations. And last but not least,
both authors were interested in the relationship between illness and deviant
behaviour.3

3. Medical Knowledge and Social Power 2: Citizenship, Michel Foucault and the
Regulation of Body and Mind

According to authors as different as Bryan S. Turner (1995; 1997; 2009), Alan

Petersen and Robin Bunton (1997) and David Armstrong (1997), the publication of
Madness and Civilization (1965), The Birth of the Clinic (1975), Discipline and
Punishment () and The History of Sexuality () introduced a breeze of fresh air in the
field of health and illness studies. This, because Foucault’s theoretical intervention
parted in important matters from the previous functionalist work that dominated the
field. Foucault’s books offered a series of critical ideas directly related to medicine,
health and illness or,that could indirectly be applied to them. From his many
contributions, due to space restrictions I have to limit my analysis to only a few.

First, Foucault’s constructivism. Put it simple, this meant that he approached the
key concepts involved in medicine and the experience of illness as discursively
constructed. Second, he developed the concept of the “medical gaze”. Third, he
offers an insightful power analytics that put together the relation between power
and knowledge. Fourth, his emphasis on governmentality and biopolitics locate the
analyses of medicine and illness within wider social processes of rationalization
characteristics of modernity. And, finally, the role of medicine in the formation of
the (modern) subject and the internalisation of norms and regulations in the form of
technologies of the care of the self. I will address these issues in turn and end the
section with a reflection on how Foucault contributes to a theory of identity
formation and at the same time requires to be supplemented in order to produce a
better account of the relation between identity formation and citizenship. This will
nicely lead me to conclude, in the last section of the paper, with an outline of a
concept of biological citizenship.

Constructivism

3
These may have facilitated a warmer reception of Foucault’s critical ideas in the 1960s in
a field still dominated by functionalism.

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In the archaeologies of modern disciplines contained in The Order of Things (1970)
Foucault showed how particular discourses created their own framework of
categories for thinking and acting. In one of his following works, The Archaeology
of Knowledge (), he explained that discourse refers to “the general domain of all
statements, sometimes as an individualizable group of statements, and sometimes
as a regulated practice that accounts for a number of statements” (1973: 80).
However, for fully understand what discourse means, one has to consider what
gets excluded, what is put out of circulation and gets fenced out of the field of
meaning. Thus the discourse of medicine not only constructs its own ‘discourse-
objects’ such as health, disease, contagion, risk group, healthy and unhealthy
behaviour, and handicap, among others, through an explicit system of statements.
Medicine’s discourse is also constituted by its ‘unspoken’ and neglected: the
exclusion of religious and/or traditional beliefs about illness and the body, the taboo
of death, the ruling out the discourse of the insane (understood as unreason and
somehow non-humane or animalistic) and the rejection of falsity (understood as
lacking scientific standard). For instance, in Madness and Civilization (1965)
Foucault showed how the rationalization of modern society required the
incarceration of what was the opposite of reason, namely, madness. Madness was
literally fenced out and presented as unreason, non-sense and unintelligible.

Discourse is not a mere framework of concepts. It is entangled with norms of

formation and constituted through social practices (discursive practices). Discourse
is embodied in institutions and historically situated experiences, beliefs and
behaviour. Indeed, the experience of a physical condition acquires meaning only
though the pathological discourse that names its illness. Lets consider some key
features of the medical discourse. Deborah Lupton says that

The discourse of science in medicine relies, in part, on the assumption that it

is politically and culturally neutral, unlike some other knowledge, such as the
articulated in lay or alternative therapy discourses (2001: 52)

Lupton quotes a study by Rapp (1990, in Lupton 2001: 52) where she claims that
the “neutralizing vocabulary, explanatory syntax, and distancing pragmatics
provide universal descriptions of human bodies and their life processes that appear
to be pre-cultural or non-cultural”.

Thus, medical discourse is an attempt to convey the distress of the ill from an
outsider’s perspective, in a distanced manner and, at the same time, aims to
provide a plausible explanation for the symptoms and the right treatment for the
normalization of the ill and his reintegration into society. As we will see soon, this
relates, on one part, to issues of power/knowledge and discipline and, on another,
to issues of governmentality and biopolitics.

Lupton (1994; 2001) also suggests that the relationship between the doctor or
nurse and patient is governed by the constraints of the medical discourse and its
idioms. And since we have a biomedical paradigm that privileges a pathological
perspective, medical discourse has tended to classify types of illnesses (nosology)

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and has separated populations and established “which kinds of people are
considered to be at risk of developing an illness and how they should be treated.”
(Lupton, 1994: 5)

As can be easily concluded from the previous, medical discourse is central to the
meaning of illness, to the definition of social boundaries and to the institution of a
‘regime of truth’ that regulates subjects based on the promotion of health and the
avoidance of illness.

Medical Gaze

Foucault developed the concept of the medical gaze in The Birth of the Clinic
(1973), whose subtitle is An archaeology of medical perception. David Armstrong
explains (1997) that the French term Foucault used - le ragard – was translated as
either ‘perception’ or ‘gaze’. He states that we should bare in mind that the French
term comprises both aspects: an active seeing, almost a searching through visual
means, and perception.

The relevance of the medical gaze is that it creates the objects of its inquiry
through its active seeing. For instance, particular symptoms and syndromes are
interpreted as forming part of the exterior expressions of inner sickness.
Classifications of illnesses depend on the work of the medical gaze that objectifies
and order them in a framework of sets and subsets.

The gaining of the medical gaze is the result of a long process of training that
involves acquisition of knowledge and, maybe more important, a becoming familiar
with the art of searching, perceiving and recognising the signs of disease.

The use of technologies deserves a paragraph here. To my knowledge, Foucault

did not develop this enough, maybe because his was a historical study about the
evolution of medicine within a few decades. However, nowadays any account of
the medical gaze has to consider the role played by a wide range of practices that
are articulated with technologies. Such is the case of diagnostic tests such as HIV
test, complete blood count, or the test of the sugar level in the blood. All these call
for the expert interpretation of the physician. Similarly, visual representations of the
body –or representations of fragments of it- now enhance the medical gaze. X-
rays, CT scanners, electroencephalograms, and ultrasounds make the inner and
invisible body parts or activities of the cells, somehow visible and intelligible to the
expert physician. In this highly technological medical setting, the voice of the ill has
largely remained silent. As Armstrong puts it, “The core task of medicine became
not the elucidation of what the patient said but what the doctor saw in the depths of
the body.” (1984: 738).

Through the clinical gaze the body experience of the ill gets erased and
fragmented into body parts for detailed examination. This technological complexity
reduces the subjective aspect and complexity of the human experience of
sickness, which becomes more and more standardised, objectified and simplified.

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Through modes of classification (nosology) and the deployment of the clinical
gaze, medicine has been able to reduce complexity, standardised treatments
through medical protocols, and, in sum, make of illness something manageable.
Sickness and the ill can be managed.

The practice of the clinical gaze articulated with medical technologies are used to
control the body. For instance, the information collected through recurrent and
normal check ups is frequently aggregated for statistical uses or for risk calculation.
Same devices are deployed onto wider population screenings to monitor disease
prevalence, especially among so-called risk groups. Needless to say that in most
occasions, the control of the body counts with the consent and even the aid of the
patient. Furthermore, in recent times the control of the body has worked through
the self-regulation of the subject who wishes to improve his health through a
healthy lifestyle. In the quest of improving the health of the population – which is
defined by modern states as a public good- “citizens are urged to turn the medical
gaze upon themselves” (Lupton, 2001: 56). I will come back to this later. Now let
me move forward to the analysis of power knowledge, governmentality and
biopolitics.

Power/Knowledge, Governmentality and Biopolitics

From the previous point it follows that the social control effected by medical
discourse and the clinical gaze should not be overlooked. For Foucault, discourse
and the medical gaze have close relations to knowledge and power. Together
these are key factors in the quest for control against the evils of chaos and
disorder. In my opinion, the description of modern differentiated society resonates
here. The key idea behind the concept of biopolitics was precisely . %

They also relate to the medicalization of society and the refinement of control
devices. As Foucault himself suggested and later Turner (1995) demonstrated,
medicalisation is a key aspect of the rationalization of society. There is what can be
called a biomedical assemblage constituted by the apparently dispersed elements
that, nonetheless, are articulated in their work upon the subject. First, there is
medical science and its emphasis in nosology -as a form of classification of illness-
and pathology. Second, there is the biopolitical preoccupation states with masses’
hygiene, prophylaxis and lately social security via health care systems. Finally,
there is the formation of a medical bureaucracy of experts and professionals. All
these closely articulated factors have facilitated the standardization of illness and,
thus, the managerial capacities of the system to cope with its potential of
disruption. Medicine has been so effective in this mission that the medicalisation
has become a key characteristic of contemporary Western (or more or less
Westernised) societies. But before continuing with the description of
medicalisation, let me develop a bit on the key notion of power/knowledge.

Foucault was interested in the local effect of power and how this is effected in the
micro level through a myriad of mundane mechanisms. This lead him out of the
domination paradigm of the sovereign power, domination and state politics. For

9
him, power flows through the intricate networks of everyday life relations as well.
This is why he became aware of how power is exerted in institutions such as
hospitals, prisons, schools and the army. Each of these institutions call for the
application of a particular sort of knowledge to rationalise and optimise the control
of its targeted population. Medicine, criminology, pedagogy are some examples.

For Foucault everybody has a certain power and, therefore, there is always a
certain space for resisting. This does not mean that individuals master themselves.
This, because even the one who resists is somehow occupying a subject position
only made possible by a counter discourse.

Foucault described this relation between power and knowledge as one of mutual
dependency. He re-conceptualised this relation introducing the neologism
power/knowledge. Foucault stated that “it is not possible for power to be exercised
without knowledge, [as] it is impossible for knowledge not to engender power.”
(1980: 52) For Foucault knowledge is always interested and is an integral part of
social and political strive. With a Nietzschean inflection, he talked of a will to
knowledge in order to refer to the continuous appetite and generation of useful
information characteristic of the modern episteme and its disciplines. The typical
procedures of categorization and measurement which I outlined earlier are again
present here because they go hand in hand with this compulsory production of
information which aims to improve social control. This search for useful information
cannot be equated with the somehow idealised search for ‘Truth’ with a capital T.
The result of the production of information is a regime of truth with its
corresponding ‘facts’. Thus scientific statements of medicine should be evaluated
and critically analysed in terms of their ‘effects of truth’. These can be perceived by
their productive or performative effect. But these effects also become apparent in
alternative forms of knowledge and other statements labelled as false and put out
of circulation because they do not comply with the standards of the regime of truth.
Such is the case of most forms of medicine that differ from allopathic medicine4
and of the experienced-based knowledge of the ill. Truth has a history made out of
struggles; it has its victorious and its defeated. Paraphrasing Foucault, the
intellectual aim is then to describe the political history of ‘truth’. However, he was
not very optimistic about the possibilities of emancipation in terms of liberating truth
from all sorts of power.

… it’s not a matter of emancipating truth from every system of power (which
is a chimera for truth is already power) but of detaching the power of truth
from the forms of hegemony, social economic and cultural, within which it
operates at the present time. (Foucault, 1980: 133).

As can be seen. Foucault was preoccupied with “the relations we have to truth
through scientific knowledge” and, particularly, with those "truth games … in which

4
The term itself seems difficult. The literature on sociology of medicine uses sometimes
interchangeably allopathic medicine, Western medicine, biomedicine, scientific medicine or even
modern medicine.

10
we are both subject and objects”. But he was also attentive to “the relationships we
have to others through … strategies and power relationships”. For him, knowledge
was for someone and for something and, hence, it established social hierarchies,
as the one between the active physician who is entitled to speak out on behalf of
medicine’s wisdom and the passive patient who has to follow the doctor’s
directions. In sum, Foucault’s concern was with “the relationships between truth,
power, and self” (1988: 15).

What has to be done then? From a Foucauldian perspective it would be important

to oppose dominant policy discourses and counter the information disseminated by
the powerful assemblage characteristic of modern medicine, health system and
other surveillant apparatuses.5 As a radical organization Vivopositivo developed
some interesting strategies which I cannot detail here due to space limitations.
However, my research shows that the following seem to characterize them. First, it
has produced a strong counter-discourses based on the figure of the activist and
the service user. Second, it has produced some unforeseen alternative knowledge
about the prevalence of stigma and exclusion based on critical social sciences and
human rights discourse. And, although it might seem more simple, it has given
voice to those who usually do not count giving them the strength to claim rights and
social recognition. People suffering HIV/AIDS became represented and visible to
the public and were ready to make open demands and accuse social stereotypes
and exclusion.

Medicine and subjectivation

It can be argued that an assemblage of articulated institutions and types of

knowledge work together in the formation of the modern subject to favour the
control and regulation of the population.6 Foucault was eager to emphasise the
importance for the formation of the individual of surveillance institutions like the
clinic and its respective disciplines such as medicine, psychiatry and the
psychology.

Foucault went further revealing the moral and mythical role of medicine. The power
of the modern “myth” of medicine is supported, according to Foucault, by the belief

5
Here I am parting in part from Foucault and coming closer to Deleuze and Guattari who thought
that surveillance apparatuses in modern societies are articulated.
6
However, in my opinion he never integrated explicitly all those contributions in an unambiguous
way and, instead, subsequently shifted his attention from the study of particular discourses and
their rules of formation, to the study of the networks of power in the micro level, then again to
the genealogy of the panoptic logic of modern institutions, and finally towards the history of the
formation of the modern subject. Thus, the obvious challenge is to integrate the contributions of
each phase of his analyses as dimensions of a wider framework. This does not mean that all
aspects can be integrated. Indeed, Foucault himself would be dubious about such a project.
Nevertheless, I believe that even his early archaeological work, which he discredited later, offers
productive insight into discourse analysis from a structural perspective, and there is no
convincing argument that prevents us to combine it with the historical analyses of his later
genealogies.

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in the “medical gaze” and its diagnosis and in the doctor’s practical knowledge,
wisdom and healing capabilities. The regime of truth generated by medical practice
is supported by its efficiency. But this is not enough, for the trust in the doctor’s
judgement has to be understood vis-à-vis the ignorance of the suffering patient.
The doctor became someone who judges what is and what is not healthy
behaviour. And in some cases, the doctors judgement is constitutive of the law
judgement, as when he has to decide about the responsibility of someone who is
depicted either as a cold blooded criminal or a madman.

But the issue of morality and medicine goes beyond such extreme cases. Since the
decline of the moral power of religion, medicine has played in modern times an
ethical role in the subjectivation of individuals. Through mundane and diffuse
practices, medicine has produced a medicalization of society. This has meant that
physicians and medical experts have gained power in society, becoming jurors not
only of what is health and unhealthy but also of what is normal and abnormal, or at
least between what is desirable and undesirable. Thus new forms of therapies –
from pharmacological, to quirurgical, to genetical- have expanded their terrains to
normalize not only the individual but entire populations. What were previously
considered normal processes, such as menopause or aging, have become medical
problems that call for medical solutions. For instance, menopause is seen now as a
health problem derived from estrogen deficit that can be restored via hormone
replacement therapies. There is a rage of advices about aging properly and
lifestyle based on medicalization. One example is the proliferation of diets
particularly rich in calcium, vitamins, free radicals and good cholesterol and low in
fat and bad cholesterol. The practice of regular sports and the use of hormones is
also advised. Other conditions, such as deafness, are defined as disabilities to be
normalized through the use of cochlear implants. That is to say, via all sorts of
technologies of the care of the self articulated with techniques of medical
intervention. In sum, medicine is nowadays a discourse not only about good health,
but also about good life and about how to live a life which is worth living.

Medicine has become a discourse about the regulation of bodies and the mind
and, ultimately, about how subjects are both conceived and formed as normal and
as good citizens. Discourses and social practices involving the promotion of health
and the search for cure through research establish and reproduce culturally
specific concepts in scientific discourse. In turn, they get internalised by self-
preoccupied patients that turn the clinical gaze towards them selves.

Health beliefs and health practices are part of a system of social and political
regulation and normalisation and play a significant role in subjects’ formation. Ideas
about the body, health and illness, and especially about the relationship of doctors
to patients, are thought to be the core of the medical paradigm and are essential
for its regulatory power.

Recent critical assessments of medicine have pointed out that this view of the
passive patient might overemphasise the representation of the patient as docile,
ignorant and dependent vis-à-vis a dominant authoritative subject position of the

12
doctor and health staff. Other medicine paradigms, such as patient-centred
medicine tend to give more voice to the subject position of the patient allowing for
personal and subjective information to be expressed and a more caring attitude of
the medical personnel to be developed. In this newer developments, the role of
social workers and psychologists as health professionals has been of paramount
importance. Nevertheless, as Lupton (2001) rightly points out, this new approaches
still are one directional and reproduce social hierarchies in the patient doctor
relation. Furthermore, one can argue from an economic rationing perspective that
these are more efficient ways of dealing with the illness from a quality service
perspective and with the ill as a consumer.

Another paradigm is the one of the self-responsible patient. In this paradigm

patients are conceived as consumer/users, able to stick to their treatments and
change their behaviour according to social expectations and medical directions
through various technologies of power – such as enforced regular medical
appointments, hospitalisation, free provision of medicine - and technologies of the
care of the self – such as the development of self-discipline in diets, safe sex
practices, regular sports, forms of meditation, psychotherapy and counselling
support -. But all these stress the principles of choice and responsibility of the
patient in taking care of his own health. In some countries such as Britain
economic incentives are being introduced in order to favour healthy behaviour.

All these medical, biological and scientific knowledge that is translated into
behavioural directions to be followed by the sick have a moralistic effect on the
subject, which suggests that these forms of medical power/knowledge subjectify
the sick (Coveney, 1998). This is what Foucault called governmentality: the
direction by someone who governs the behaviour or conduct of the governed.7 In
this case, governmentality expresses an ethics in the idiom of pastoral power; a
power that cares for the sick population and its promotion for the sake of the whole
of the community which also constitutes a form of self.8

In the previous discussion of Foucault’s key concepts identity and citizenship

appear merely as shadows against the ghostly image of an absent subject. There
are only subject positions discursively constructed. And individuals play those
subject positions. The subject is an effect of power.

But, is that all there is?

7
In this respect we disagree with Coveney’s interpretation. On “pastoral power”, see Foucault,
“Governmentality” (in the Faubion volume on Power), in which he defines “pastoral” power as
part of the genealogy of the development of governmentality.
8
Foucault states: “Through … different practices - psychological, medical, penitential,
educational - a certain idea or model of humanity was developed, and now this idea of man has
become normative, self-evident, and is supposed to be universal.” (1988: 15).

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4. Conclusion: An outline of the concept of Biological Citizenship

I will not recur to the last period of Foucault in his works on ethics to correct his
strong anti-humanistic programme of his theories of discourse, governmentality
and biopolitics. Instead, I will relate his notion of the subject and subjection to the
one of subject position and identification as developed by Chantal Mouffe.
Mouffe (1992) has stated that citizenship is a particular kind of identity category. It
can work as an articulatory principle, as nodal point, as an anchoring concept. She
states that citizenship

… is an articulating principle that affects the different subject positions of the

social agent … while allowing for a plurality of specific allegiances and for
the respect of the individual liberty (1992: 235)

Mouffe supplements Foucault through a theory of identification. For her, the subject
is divided by a series of subject positions; is internally diverse and split. His/her
identifications are the other side of discursive subjection. The resulting
identification is always temporal and contingent, but nonetheless rather stable and
non-voluntaristic because it is discursively structured. How to understand biological
citizenship within this framework of identification/subjection?

I understand biological citizenship as one sort of allegiance with which individuals

can identify. What makes it appealing? Biological citizenship is as an emerging
dimension of citizenship that empowers people by entitling them to claim politically
new rights related to the field of biopower. In other words, biological citizenship is
not necessarily about biological rights, such as reproductive rights, but about
politicising biomedical issues and group-based demands and interests by claiming
a universal justification of the rights of the citizen that emerge in the field of
biopower.

This view of citizenship fits within an ethos of pluralization. The necessary notion of
legal status is supplemented with a notion of citizenship qua process: the process
of claiming rights. In this regard, the basic assumption is that in contemporary
societies people can defend their right to claim their rights, expand them and
create new rights. Thus identity and citizenship become interrelated in plural
societies because there is this expanding notion of rights related to the various
subject-positions that crisscross identity. Therefore, it is possible to talk today of
environmental, cultural, aboriginal, sexual or disporic citizenships (Isin & Wood,
1999; Turner, 2009).

Biological citizenship and patient organizations qua emerging forms of political

identities are constructed through a web of relations, discourses, subjectivation
technologies and institutional strategies that form an emerging configuration of
power/knowledge in the field of biopower.

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The new configuration of seems to be conflictive and crossed by tensions that call
for case-specific analyses. Nonetheless, it seems to me that one can speculate
that there are two main poles in this tensioned field of biopower: on the one hand,
scientific discourses such as biomedicine, genomics, public health and public
policy and the(ir) respective regimes of truth and forms of subjectivation and, on
the other, radical political discourses of patient organisations that put forward
unprecedented understandings of identity, citizenship and politics that empower
people through forms of self-governance and practices of freedom (Tully, 2001)
that also articulate forms of scientific knowledge in their favour.9 My research has
shown me that in this particular case of Vivopositivo medical information and
knowledge gets .recontextualised into patient’s collective representations and
discourse through an active re-reading based in activists strategic objectives. For
instance, they update their clientele by disseminating new findings in the field of
HIV/AIDS and, at the same time, remain critical of laboratories and the government
policies in the matter.

Biological citizenship emerges as a new form of political identity that creatively

combines the discourse of biomedicine with activists’ discourse on participation
and figures of citizenship struggles. The framing of the discourse on the disease is
particularly illustrative. Frequently, the disease is represented as the enemy and a
series of warfare-like figures are used and plague its rhetoric (Rabeharisoa and
Callon 1999). This positions the patients as active citizens or warriors in agreement
with the concept of biological citizenship and its ideal of self-determination and
autonomy which I am suggesting here.10 Furthermore, patients become active
agents of their condition as users of health services and co-participants in the
process of creation of knowledge as experts in experience of similar worth
compared to scientific experts. This was particularly relevant during the first times
of AIDS when very little was known about it. Doctors relied for refining their
research and therapy on patients’ accounts and self-monitoring.

I will finish this paper enumerating what I think are some key feautures of biological
citizenship. First, biological citizenship is as much about recognition as about
access to formal rights.

Second, in the case of biological citizenship, groups are formed around biological
components and, hence, specific identities are constructed around those biological
attributes. Thus, here the membership is not based on the choice of a rational
individual that decides for or against an ideology. Instead, membership is
9
Foucault’s emancipatory move does not rely on a humanitarian ideal: “Humanism may not be
universal but may be quite relative to a certain situation. … This does not mean that we have to
get rid of what we call human rights or freedom, but that we can't say that freedom or human
rights has to be limited at certain frontiers. What I am afraid of about humanism is that it
presents a certain form of our ethics as a universal model for any kind of freedom. I think that
there are more secrets, more possible freedoms, and more inventions in our future than we can
imagine in humanism as it is dogmatically.” (1988: 15)
10
Michaela Mayrhofer made me aware of this in an unpublished paper given in a conference in
Exeter University in 2006.

15
seemingly predisposed, though not determined by fatality. For instance, many
relatives of patients take part in patient organisations without carrying themselves
any biological mark. Identification with the experience of a significant other is
sometimes enough. Also because illness is no longer seen as fate the social
construction of a sense of hope can create a shared solidarity and brings people
together.

Third, advanced views on citizenship have expanded the scope of the concept and
theory to cover a range of phenomena beyond the public realm and the state
(Lister, 2007; & Turner, 2007; Plummer, 2001; Schild, 1998; Jelin, 1998). Under
this light, Lister has stated recently that “the key determinant of whether or not an
action constitutes citizenship should be what a person does and with what public
consequences, rather than where they do it.” (Lister, 2007: 57). Thus, biological
citizenship can fruitfully be seen as a practice that works in the space where the
private and the public intersect one another, publicising intimate experiences and
emotions such as pain. This is a necessary supplement to the notion of citizen as a
status or a locus of rights.

Fourth, it has been a prominent feature of theories of citizenship, from Marshall

onwards, to conceive it as an inclusive normative ideal. T.H. Marshall provided a
critical social theory when conceiving citizenship as a regulatory ideal based on “an
image of an ideal citizenship against which achievements can be measured and
towards which aspirations can be directed” (1973: 29). Accepting Marshall’s
normative move, one important development over the past decade has been the
various ways in which scholars and activists have developed citizenship’s potential
to include people based on the centrality of categories such a difference,
multiculturalism, identity, recognition and intimacy. All these reflect the centrality of
cultural identity and the private realm of life to contemporary citizenship struggles.
Similar to those, we think that illness can become a strong intimate identity marker
on the basis of which a new type of identity claim is articulated. Let us develop
further our argument.

Fifth, biological citizenship cannot be reduced to its juridical dimension without

paying the cost of elaborating a static category. Instead, we conceive the
recognition of biological citizenship as the result of historical processes of context-
dependent social struggles or as a process characterised by tensions between
different social principles, logics and social trends.

Sixth, and related to the previous point, we must avoid sweeping generalisations
and, instead, we have to conceive biological citizenship as a context-dependent
political category resulting from an ongoing and cumulative process of social
construction that has built citizenships in plural – civil, political, socio-economic,
cultural, biological, etc. This view is coherent with a “differentiated citizenship”
(Young, 2001; Kymlicka & Norman, 1994).

Seventh, biological citizenship relates to the field of biopower and biomedicine and
directs its claims to the welfare state, biomedical corporations, public and private

16
laboratories, biobanks and medical expert systems. This is the side of the demand
of the constitution of biological citizenship.

Eighth, there is a self-promotion aspect to biological citizenship. For instance, the

particularity of the patient organisations is that it has empowered its members
through strategies of self-governance. To finish this paper let us suggest that the
notion of biological citizenship will be used more and more by scholars researching
in the field of biopower and biopolitics (a majority maybe following the post-
Foucauldian fashion). Let us hope that its use will not confine it to be another
theoretical and abstract notion to complete the Foucauldian edifice of genealogies
of modernity. Our wish is that biological citizenship can become a dynamic
category used to grasp very concrete self-government experiences of people who
oppose and negotiate disciplinary regimes. Our commitment is to deepen this line
of inquiry in our further research.

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