By Gordon Hull
Since we’re in the interregnum between “sign up for health insurance” time and “eat yourself into a stupor” time, it’s appropriate to notice something about pastoral power and our healthcare system. First, we’ll go back in time. Foucault proposes that pastoral power under medieval Christianity:
“Gave rise to an art of conducting, directing, leading, guiding, taking in hand, and manipulating men, an art of monitoring them and urging them on step by step, an art with the function of taking charge of men collectively and individually throughout their life and every moment of their existence.” (Security, Territory, Population (=STP), 165)
He then urges that this is not the same as political power, the power used to educate children, nor is it persuasion (“in short, the pastorate does not coincide with politics, pedagogy, or rhetoric” (164)). The pastorate does not disappear with the rise of modern power forms, as he emphasizes in a couple of places (STP 148, 150). Indeed, he makes a much stronger claim: “I think this is where we should look for the origin, the point of formation, of crystallization, the embryonic point of the governmentality whose entry into politics … marks the threshold of the modern state” (165).
One of the pastor’s responsibilities, then, is surveillant, because to guide the flock, you have to know the flock: “the pastor must really take charge of and observe daily life in order to form a never-ending knowledge of the behavior and conduct of the flock he supervises” (STP 181). This function is very similar to what he calls the “swarming of the disciplines” in Discipline and Punish (p. 211) where disciplinary institutions extend their data-collecting reach (by talking to the neighbors of truant children, for example, about the prayer habits of the children’s parents), as well as the dissemination of the procedures themselves.
One of the central ways this epistemic function happens is to get the individual members of the flock to produce (and desire to produce) their own truth about themselves. That is, after all, both efficient and probably more efficacious. And one of the main vehicles for such production is the confession (not emphasized particularly in STP, but it’s a main theme of History of Sexuality I (=HS1)). In HS1, Foucault proposes that “since the Middle Ages, at least, [confession is] one of the main rituals we rely on for the production of truth (HS1 58). As he notes:
“One confesses in public and in private, to one’s parents, one’s educators, one’s doctor, to those one loves; one admits to oneself, in pleasure and in pain, things it would be impossible to tell anyone else, the things people write books about. One confesses – or is forced to confess” (HS1 59)
There’s a lot to say here (and the lectures in On the Government of the Living (1979-80) make it a central piece, and I haven’t finished those yet, so my remarks on confession in Foucault here should be taken as placeholders for a better investigation), but I want to focus on confession as it manifests itself in two modalities of power here.
One such modality is the law, and can be seen in testimony: under solemn oath I relate what I saw; before the judge I confess my crime in hopes of leniency in the law. As a matter of record, witness testimony is very unreliable, and in the U.S., confession is usually used as a technique of policing: we will charge you with – and convict you of – Big Crime A, unless you confess to little crime B, which carries a lower penalty. This technique for avoidance of trial indicates that confession is perhaps even more important today than any formal description of our legal institutions would indicate. On the other hand, if I am Catholic, I am supposed to confess on a regular basis. But how do we know these confessions are true? What if I don’t go to confession every week? And the confession is supposed to put me on the path to behavioral change. With all these barriers, turning confession into an actual production of truth which then changes the subjectivity of an individual is tricky, since individuals who aren’t fully convinced of the value of the regime demanding confession have every incentive to be less than totally forthcoming, even if they are required to confess.
The other modality is regulation by code – something Lawrence Lessig explores in detail with regard to the Internet (see this book). Any time you are unable to skip the copyright notice or ads in front of a DVD, you’re experiencing code-based enforcement, not of law, but of a corporate desire. Lessig wants less code-based regulation, but to be fair, there is a normative case to be made for it, insofar as it’s a lot more fair in the sense that code causes a lot more people to comply with the law than the law+punishment dyad (you could argue that it’s less susceptible to racist enforcement, too, but of course where one puts the speed bumps isn’t an innocent decision). Comparing the regimes of power is thus the comparison between traffic police and speed bumps. Before getting to the normative case (which I won’t in this post), however, it’s worth noting an area where confessional logic and the technologies enabling code-based enforcement are increasingly encroaching into our lives: employee wellness programs.
A lot of employers these days offer some sort of financial incentive to those who are willing to confess their daily habits to the insurance company (or the employer). For example, those covered by the North Carolina State Employees health plan have a growing number of ways to reduce their premiums by confessing their health status. You’re supposed to have a primary care physician; you’re supposed to watch a video touting a fancier name for this and explaining in patronizing terms how this makes your care coordination much better; you swear that you don’t smoke; and you update some biometric data (like blood pressure, blood sugar count, weight, etc.) into their website. They swear that nothing bad will come of your entering this data, and that may be true, but notice that there is a direct tie established – and taught – between salvation in the form of lower insurance premiums, and the confession of one’s health habits.
But, as we know, financial incentives generate all kinds of other incentives – like lying about whether you smoke or exercise. Indeed, people don’t seem to be all that compliant and (for some reason!) experience these little exercises in data entry as annoying, intrusive, and paternalistic. So, as Bruno Latour observed a long time ago, we outsource a lot of our moral enforcement to devices like automatic door closers and automatic seat belts. So imagine a plan that requires employees to wear fitbits or other electronic monitoring devices as proof that they're trying to lose weight or lower their blood pressure. At that point, we have the logic of confession as an extension of a pastoral mandate to the salvation of the flock, omnes et singulatim (the omnis part in the form of reduced healthcare costs, and the singulatim in that you have to wear the device). The granularity of such surveillance is pretty good already and certain to increase in the future, as insurance companies learn to mine their data (or purchase it cheaply from others) for risk factors and predictors of poor outcomes. Some of this data won’t be data you provided (or thought you were providing), as data brokers will learn how to associate either seemingly unrelated data (furniture purchasing habits and diabetes risk: do you tend to comfy sofas?) or metadata (do you spend a lot of time on the phone with other couch potatoes? How about playing multiplayer video games?).
In doing all this, wellness programs would represent an intensification of the logic of confession, applied to the intersection of health and work. As Susan Hansen notes, the way for such monitoring was paved by earlier “employee assistance programs” that are designed to detect when employees are encouraged to report personal problems that might make them less efficient at work (say, breakup of a marriage), and thereby direct them to helpful “lifestyle management programs.” Another source would be the older models of employer-built recreational facilities, and the disappearance of these combined with the emergence of health coaches and theories of individual responsibility. The combination aims at nothing less than a re-interpretation of our traditional concept of the employment-health relation: “Under health promotion logic, workplaces are now recognized as places that can be ‘good’ for, rather than deleterious to, your health and well-being” (130).
All of this is not to say such things as these are actually good. For one, they distract attention from anything public about health, from regulation of carcinogens to zoning laws that make it impossible to walk anywhere. And, of course, living under a regime of constant surveillance might make one feel less attached to work, and more stressed while there:
“In this attention to personal problems – as the source of potential costs to productivity – workplace monitoring practices and other ‘stress-inducing’ workplace practices are effectively excluded from serious consideration as a credible source of unease, discontent, and associated grounds to inefficiency” (Hansen, 163).
Hansen concludes that the current programs represent a “transition … from a form of governance characterized by a pastoral mode of control and care to a neoliberal form of discipline, marked by an increasing reliance on the motivation of workers towards self-management, self-monitoring and self-correction” (160). I think this is basically right, but we need to notice that the neoliberal effort at motivation exactly coincides with the pastoral model of offering “salvation” for the willingness to wear confessional technologies and to confess to drinking too much last night when you read your employer’s health plan. We also should notice the dependence of this model on developments in surveillance technologies and how they are understood as techniques of governmentality. They trade on the presumed truth of medicine, and, as one paper put it, “this health promotional logic appears to provide medicalized legitimacy for the organizational governance of an employee’s subjectivity” (132).
It’s a little out of context, but it Foucault also underlines the extent to which such pastoral regimes are to undercut resistance in the form of critical thinking by demanding absolute obedience of the flock. Foucault cites Saint Gregory Nazianen, who defines the pastoral governmentality as the “art of arts.” What used to hold that term? “It was philosophy. That is to say, well before the seventeenth and eighteenth centuries, what took over from philosophy in the Christian West was not another philosophy, and it was not even theology; it was the pastorate” (STP 151). You see, this constant monitoring is empowering, and is evidence that the company cares about you! No need to worry. You'll be fine, better than fine. But don't you dare have more than one glass of champagne to celebrate.