Care of the Self and American Physicians' Place in the “War on Terror”: A Foucauldian Reading of Senator Bill Frist, M.D.

Abstract

American physicians are increasingly concerned that they are losing professional control. Other analysts of medical power argue that physicians have too much power. This essay argues that current analyses are grounded in a structuralist reading of power. Deploying Michel Foucault's “care of the self” and rhetorician Raymie McKerrow's “critical rhetoric,” this essay claims that medical power is better understood as a way that medical actors take on power through rhetoric rather than a force that has power over medical actors. Through a close reading of an essay by Senator Bill Frist, this paper argues that physicians experience a process of “subjection” wherein they are both agents of and objects of medical power as it is combined with state and corporate power in the American “war on terror.” This alternative mode of analyzing medical power has implications for our collective understanding of its operations and the means by which we propose alternative enactments of medical power.

Keywords:

• care of the self
• Michel Foucault
• power
• professional control
• rhetoric in medicine
• William H. Frist

I. INTRODUCTION

Medicine has experienced many changes in the last ten years. Among these are the move from pay-as-you-go insurance policies to health maintenance organizations (HMOs), a greater focus on evidence-based medicine instead of clinical experience, and the emphasis on medicine as science rather than medicine as art. The greatest shift, however, may be changes in physicians' ability to exercise power in medical relationships. Consumer-driven models of healthcare may be becoming the standard for “good” medical practice (Reagan, 1999). When consumerism becomes the model, medical professionals may lose control of their work, and the state and corporations may increasingly control the practice of medicine (Krause, 1996). “Healthcare” as opposed to the bio-psycho-social needs of patients and providers may enact a Fordist system in which physicians are only one part of “assembly-line” medicine (Wolf, 1997).

These “new” developments may not be that new. At least since 1906, physicians have been driven to become more technician than doctor as they experience economic pressures for efficiency and productivity (Furst, 2000). Although the view of the physician as a mechanic may not be new, those who are concerned about the disempowerment of the physician may also be concerned about recent recommendations made by the United States Institute of Medicine to standardize patient care (2003) so that safety, effectiveness, patient-centeredness, timeliness, efficiency, and equitability of care can be easily measured by patients, government, and insurers (2001).

Although the focus on standardization and objective measurement may disempower the physician, most discussion of medical power indicates that physicians have more power than other individuals. The focus on the possession of power, however, may fall short in understanding the relational nature of power in medicine. Because power is relational, and because physicians use power and are manipulated by power, a deeper investigation of how physicians become implicated in power relations may help us better understand the operations of power in the medical system.

I begin this investigation by reviewing the use of the French philosopher Michel Foucault's concepts to analyze the operations of power in medicine. Because there is a strong commitment to structural readings of power in these studies, I draw on rhetorician Raymie McKerrow's “critical rhetoric” to offer an alternative mode of analysis. Under this mode, I outline Foucault's principles of “care of the self” that help to enact this critical rhetoric. To demonstrate the applicability and the heuristic value of this perspective, I offer a close reading of an essay by Senator Bill Frist, M.D. that works to subject physicians and/as citizens through care of the self. Following this appraisal, I offer conclusions and implications that this focus has for understanding medical power.

II PAST PRACTICE OF FOUCAULDIAN MEDICINE

Michel Foucault's ideas have been widely used to discuss the operations of power in and through medicine in society. Although Foucault's work became more complex as he further explored the problematics of power, much of the use of his work has remained committed to his early, structuralist thought. Related to this focus on structure has been a de-emphasis of Foucault's concern for “subjection” in the History of Sexuality project (Frank & Jones, 2003; Petersen, 2003; Goldstein, 2003). Judith Butler notes that a structuralist focus on power is one in which a classical model is adopted; i.e., “power imposes itself on us, and, weakened by its force, we come to internalize and accept its terms” (1997, p. 2). An alternative model is one that does not rely on submission, but on subjection, “the process of becoming subordinated by power as well as the process of becoming a subject” (Butler, 1997, p. 2). That is, power is not just repressive; it is productive of positions within social orders.

Researchers drawing on Foucault have been most concerned with power as coercion. Although these analysts insist that power inheres in relationships, the thrust of the analysis is such that power becomes a possession that some people have and others lack. The power of the medical actor over the patient has been analyzed as an instrumental coercion of the patient throughout the life-course, from prenatal development to maturation to death (Hick, 1999; Goldstein, 2003; Harley, 1994; Willems, 2000). Coordinated with power over patients is the discourse of “expertise” which operates to justify this exercise of power (Rawlinson, 1987; Candlin & Candlin, 2002; Cheek & Rudge, 1994). Although reference is made to discourse, the materiality of power over patients is central to these analyses. This structuralist reading is laid most bare in the parallels drawn between physician-corporate management and patient-worker obedience (Butchart, 1996; Brown, 2004; Zoller, 2003) and in the neoliberal concern for individuals' “rights” to competent and informed decision-making (Prado, 2003; Ellis, 2003).

This transformation of Foucault into a structural determinist results, most likely, from the decision to take two of Foucault's metaphors for relational power—surveillance and governmentality—as structural mechanisms of power. The autopsy table and the prison are Foucault's exemplars of surveillance (1978 1979). When these concepts of surveillance are deployed, however, analysts of medical power transform the metaphoric table and prison into the essential nature of medical practice, arguing that a patient who is treated is always autopsied or imprisoned in a strong material sense (e.g., Peckover, 2002; Rendell, 2004; Holmes, 2001; Fahy, 2002; Dreyfus, 1987; Casey, 1987; Gibson, 2004; Ellis, 2003). Although Foucault's metaphors provide insight, the metaphors are stretched so that significant differences between the prison and medicine and between the autopsy and other medical interventions are ignored.

Foucauldian analysts have used the concept of governmentality more productively. Governmentality is a style of power-knowledge in which growing bodies of knowledge coupled with rituals of truth allow experts, institutions, and disciplines to lay claim to the power of governance (Foucault, 1986b; 1989). Medical power is informed by intersections of power relationships among industry, government, the professions, and other loci (Elwyn, 2004; Schillo & Thompson, 2003; Pollock, 2003). Medicine, as a discipline, has claimed governance over many social sectors (Holmes & Gastaldo, 2002; Brown, 2000; Petersen, 2003). This governance has largely been translated as professionals' power over people who are medicalized. The normalization of medical power-knowledge and/as governmentality has been observed generally (Scott, 1987; Manias & Street, 2000) as well as within subdivision of the medical field, including nursing (Georges, 2003; Ceci, 2003; Riley & Manias, 2002), administration (Learmonth, 1998; Gilbert, 2003), public health (Rock, 2003; Petersen, 1995), clinical medicine (Ong, 1995), and social services (Gilbert, 2003). In addition to effects internal to the medical field, medicine coordinates with other fields of governance to regulate the social (Petersen, 2003; Nye, 2003). Governmentality coordinates the sociological, moral, criminal, religious, and medical into a shared domain wherein different forms of power-knowledge help normalize one another (Weir, 1996; Kinsman, 1996; O'Malley, 1998; Cruikshank, 1993). Moreover, just as medical power-knowledge contributes to governmentality in these shared realms, administrative, corporate, and other forms of power-knowledge contribute to the normalizing forces in medicine (Smith, 2000; Cloud, 1998; Lynch, 2004; Brown, 1994). As governmentality has evolved in the medical literature, it has become increasingly reliant on a priori categories in which one group has power over other groups.

Surveillance and governmentality ask “who has power” and “where is power located.” Although such questions are necessary to a structural analysis, to be more poststructural we need to ask “how is power exercised” and “how do people become drawn into subjectivities.” Frank & Jones (2003) suggest that power cannot be treated as if it stood outside relationships where power is articulated. In looking at power over subjects rather than power through subjection, the productive elements of power are discounted in favor of the repressive hypothesis (Petersen, 2003; Goldstein, 2003; Frank & Jones, 2003). Although the repressive hypothesis is useful for struggle against the current order, it is not an alternative to power (Foucault, 1978). Instead, the political options offered under the repressive hypothesis call for resistance or the founding of an alternative discipline.

III CRITICAL MEDICAL RHETORIC: A THIRD WAY

Calls for resistance and alternative disciplines recognize that power operates in/as a discursive relationship and not as a possession. Instead of dominating, as in the repressive hypothesis, or liberating, as in the utopian prospect, discourses require the active participation of the subject to enact a repressive or utopian project (Barker & Cheney, 1994; Clegg, 1989; Ryan, 1991). Although this requirement is admitted, it is rarely addressed by analysts of medical power. In the field of communication studies, rhetorician Raymie McKerrow recognized similar limits in how Foucault's ideas were being employed. Rather than beginning with the theoretical concept and working down to the text, McKerrow urges the analyst to begin with instantiations of discourse.

Previous uses of Foucauldian theory have been based on resisting oppression. Because these analyses examine “discourse as it contributes to the interests of the ruling class” and use that analysis to empower “the ruled to present their interests in a forceful and compelling manner” (McKerrow, 1989, p. 93), these analyses are no longer poststructural deployments of Foucauldian theory but enactments of traditional ideology critique that happen to cite Foucault. McKerrow holds that because they “focus on the hierarchy of dominant/dominated,” traditional critiques that happen to employ Foucault “fail to examine the critique of power relations across a broader social spectrum” (1989, p. 96).

McKerrow (1989; 1991) argues that there are at least two strains in Foucault's thought that operate from the early to the late work to authorize an alternative path of analysis. The first strain is the critique of domination. McKerrow notes that this critique has a focus on “the discourse of power which creates and sustains the social practices which control the dominated” (1989, p. 92). This strain is concerned with analyzing who has power over whom and relies most strongly on the repressive hypothesis. Although the critique of domination is necessary, the libratory narrative that it authorizes quickly reveals the need to do more. To address this need, McKerrow offers a second strain of criticism: the critique of freedom. McKerrow defines this critique as “our chance to consider new possibilities for action,” not the search for “a particular normative structure” that counters repression (1989, p. 94). This strain is concerned with analyzing how power through subjects is enacted. As McKerrow puts it, “a ‘critique of domination’ implies freedom from powers of oppression,” the search enacted in much Foucauldian criticism, whereas “a ‘critique of freedom’ implies freedom to pursue other power relations” beyond current neoliberal or Marxist options (1991, p. 75).

Although neoliberal and Marxist critics (Charland, 1991; Cloud, 1994) claim that McKerrow denies future visions of improvement, Hariman (1991) notes that McKerrow offers a continuous vision of critique that points to errors of the repressive structure as well as errors of libratory alternatives that would enact their own disciplinary regimes. In addition, a continuous critique of freedom is needed to avoid the “twin diseases” of fascism and Stalinism, potential futures of the unexamined liberal and Marxist visions, respectively (Foucault, 1982, p. 209). Although the lack of prescription of the “correct” relations of power may be dissatisfying to the activist, the skepticism of universalist dogma allows the constant critique of power relations, prevents totalizing analysis that enacts “self-evident” experience, knowledge, and power, and frees new possibilities for thought and action. That is, if neoliberal and Marxist orientations — accompanied by their predetermined end — are deployed, the new power structure that they would propose is at least as repressive as current forms of domination, albeit repressive in different ways and with different principles.

At the center of McKerrow's articulation of the critique of power and the critique of freedom is Foucault's “care of the self.” As these critiques are enacted through critical rhetorics, they coalesce into a reflexive body of partial power-knowledge over and through the self. In a critical rhetoric, self-discipline and social discipline may become mutually reinforcing. In this way, “the care of the self—or the attention one devotes to the care that others should take care of themselves—appears then as an intensification of social relations” (Foucault, 1986a, p. 53). Instead of caring for others or caring for oneself, the care of oneself and the care of others tap into “the whole bundle of customary relations of kinship, friendship and obligation … It was a duty that one was performing when one lavished one's assistance on another, or when one gratefully received the lessons the other might give,” not an interference with selfhood (Foucault, 1986a, pp. 52–53). Moreover, these bundled social relations allow discourse to pervade the personal and the social. Rather than a self that is determined by others only, care of the self allows discourses to have power over people even as these same people take on power through these practices. As such, even as the subject seeks freedom from control by others, care of the self gives the subject freedom to act in ways that rearticulate these same power relations. In this manner, care of the self enables “a close connection between the superiority one exercised over oneself, the authority one exercised in the context of the household, and the power one exercised in the field of an agonistic society” (Foucault, 1986a, p. 94). The inverse connection is also present; if care of the self coordinates social standards with superiority over the self, social standards may also be adopted by the subject in the household and larger society.

IV ANALYSIS

To illustrate how care of the self becomes a practice of self-discipline, I offer an analysis of an essay written by Senator Bill Frist, M.D. (2002) for the American Medical Athletic Association Journal. Frist is a unique actor in the American medical and political systems. Frist is a former member of the Senate Health, Education, Labor, and Pensions committee and the current Senate Majority Leader. In addition to holding powerful political positions, Frist is the first practicing physician elected to the United States Senate in over 50 years. Frist, a board certified heart surgeon, has performed more than 200 heart and lung transplants. He may also be the most active academic writer in Congress, having written more than 100 articles and chapters, as well as three books. As indicated by his title, Frist embraces the role of legislator and surgeon equally, giving him a unique ability to cross two communities and to have influence in both.

Frist's essay serves as a recreation of an argument that physician physical fitness is intrinsically linked to American national defense. Frist's essay is a “representative anecdote” of how care of the self is used to discipline medical professionals. A “representative anecdote” allows the analyst to engage an extensive body of discourse by using a segment of that discourse for closer analysis (Burke, 1969). The analyst can use this segment to derive a “motivational calculus” that drives the larger discourse. In selecting a set of texts as the representative anecdote, the motivational calculus derived from the smaller set “must be representative of the subject matter” and “must be supple and complex enough to be representative of the subject matter it is designed to calculate. It must have scope. Yet it also must possess simplicity” (Burke, 1969, p. 60). By identifying the themes in a segment of this discourse, the analyst can then make claims about the larger discourse of which the analyst's sample is a subset. An analysis of Frist's speech may help to delineate the role of power-knowledge in structuring medico-political relations. By taking advantage of two sets of knowledge—medical and political—that authorize his speaking in both realms, Frist takes on power. Moreover, as a voice heard to be legitimate, Frist may exercise this power to authorize new understandings of medico-political relationships.

Frist begins his advocacy by identifying the physician as a subject in the war on terror. This relationship serves as the primary structure for social relations advocated by Frist. After noting that the terrorist attacks on the World Trade Center have called for greater responsibility of all people in the United States, Frist argues that “We must now … defend our homeland against further terrorist attack. We can, and I believe we will, win this war and protect America. But victory will require the focus, energy, and determination of each and every one of us” (2002, p. 12). Frist's extensive use of plural pronouns may help to promote identification between the physician and the American public. Additionally, this identification implies that the response to the attack requires the active participation of physicians. That is, physicians are given a plural investment in the war on terror as victims and as avengers of the events of September 11, 2001.

In addition to physicians becoming invested in Frist's argument, Frist indicates other structural relationships that came under attack and the physician's role in defending current structures. Frist argues that the danger is not only to the physical body but to the very structures that define the American system. He states:

These terrorists are intent not only on killing innocent men, women, and children, but on destroying our very way of life—paralyzing our system of government, crushing the prosperity of our economy, and stealing the liberties that we have enjoyed for more than two and a quarter centuries. (2002, p. 13)

By making the attacks ideological, and not just physical, Frist argues that the attacks implicated parts of larger systems of governmentality. Republican forms of government, capitalist economic practices, and the tenets of liberal democracy are coordinated with the physical threat of terrorism so that an attack on one is identical with an attack on all. This coordination of physical safety with other realms of power-knowledge outlines a parallel responsibility for physicians. Because physicians were identified with the workers at the World Trade Center, and because the World Trade Center came under attack to undermine American safety, government, economics, and politics, physicians were also attacked for their participation in these forms of governmentality. The answer to these attacks, however, is not to surrender current modes of governmentality, but to defend these elements. By identifying a core enemy through that enemy's opposition to America as republican, capitalist, and democratic, those who would oppose terrorism must also support republicanism, capitalism, and democracy.

Beyond the bipolar opposition of terrorists against Americans/physicians and/as republicans/capitalists/democrats, Frist indicates that his audience must be prepared to act on this opposition. Frist posits that Americans/physicians, joined on this common ground, are in continued danger. He argues, “We do not know the form such an attack would take—conventional, biological or radiological … We must be fully prepared for the potential of a terrorist attack in any place, at any time, and in any form both as a nation and as individuals” (2002, p. 12). To further engage his audience, Frist outlines linkages among forms of governmentality that bring physicians onto those common grounds. One linkage is between the larger American public and the physician as learned intermediary. Frist encourages physicians to take advantage of education opportunities to increase their knowledge of terrorism generally and bioterrorism in particular. Frist argues that “one vital element to our national preparedness that I believe is often overlooked is education. Every American, especially those of us in the medical community, should know the basic facts about bioterrorism” (2002, p. 13). Given the power-knowledge relationship outlined by Foucault, this increased knowledge of bioterrorism should also allow physicians to become more influential in discussions of terrorism. This influence, however, is checked by the need for physicians to coordinate their action with the government. The second linkage between physicians and the larger war on terrorism is the subordination of medicine to the needs of the state. Along these lines, Frist offers praise for the Bioterrorism Preparedness Act of 2001. “This legislation,” Frist asserts, will “foster better coordination between government and the medical community, and provide incentives for the research and development of better treatments and vaccines. These are all positive steps that our nation must take to better prepare for a potential terrorist attack” (2002, p. 13).

In addition to these previous acts of coordination, Frist encourages a final linkage dependent on the preparedness of physicians. This is not an external relation of responsibility that the educational system has to physicians or that physicians have to the state. Instead, this linkage is an internal responsibility of the physician to be ready to act as a physician. Frist insists:

Those of us in the medical community have a critical role in this effort. We are among the front-line soldiers in homeland defense. When a patient walks into a doctor's office with an unusual rash, lesion, or other symptom, it is our job to make a proper diagnosis. When emergency crews are dispatched to the scene of a terrorist attack, their next stop is our emergency rooms. In both circumstances, the lives of thousands of people could be hinging on our ability to respond quickly and effectively. (2002, p. 12)

Making a diagnosis is part of the traditional responsibility of the physician. So is providing care in an emergency. Frist's language, however, coordinates these traditional responsibilities into responsibilities to larger systems of governmentality. His military language, and the hinging of the whole effort on physicians, makes strong grounds for a critique of power. Physicians are brought under governmentality in the coordination of republicanism, liberal democratism, capitalism, militarism, and medical practice. The combined efforts of these systems of power-knowledge could be read as attempts to coerce the physician. Frist's argument, though, realizes that the physician cannot be forced into medical practice. The physician must be brought to accept this position.

As these social structures are integrated, Frist uses the principles of the care of the self to engage his audience and to allow their cooperation. Despite being part of a governmental vision, Frist limits the physician's direct responsibility to being able to respond quickly and effectively in the event of a terrorist attack. Although this direct responsibility is limited, the scope of participation within this vision has broad implications. Frist's only apparent requirement for the physician to be a “good” actor is that they be physically fit. He states that, in the war on terror, “doctors, nurses, administrators and other health professionals must be in sound physical and mental condition when so much is asked of us and so much is at stake” (2002, p. 12). This conditioning, however, moves beyond the physical body. It is, instead, coordinated with support of the state and other preferred regimes of power-knowledge.

This conditioning is also a productive force of physician identity. The care of the self has mental and physical conditioning effects. Drawing on generally accepted beliefs about physical fitness, Frist asserts, “We all value the physical benefits of exercise—being in better shape, living a healthier lifestyle, and decreasing our general risk to disease” (2002, p. 12). The relationships among forms of exercise and physical well-being are well established. Beyond the flesh, Frist argues that “there are also psychological benefits” to exercise; “exercise sharpens the mind so that we can be better prepared for the challenges that lie ahead—whether it's day-in and day-out medical work or the rush of a medical emergency” (2002, p. 12). Within this regime of the care of the self, the individual may, then, become more physically fit and mentally awake. In addition to these individual benefits, Frist also indicates how this conditioning may also affect a person's social belongingness. Frist argues that, although most benefits from exercise are to the individual, “we shouldn't forget about the spirit of camaraderie that so often springs from athletic activity … Athletics, just like being involved in your church or volunteering in your community, is a great way to strengthen the common bonds that unite all Americans” (2002, p. 12). In other words, care of self makes a person a greater part of the American community.

Frist then demonstrates how the care of self translates into a better self and a better social actor. Frist claims that, “as a transplant surgeon, I couldn't predict when an organ would become available. I had to be prepared for the unknown” (2002, p. 12). This awareness of how a physician must be ready to act at all times under conditions of uncertainty includes more than being ready for the operating room. Under current conditions, Frist argues that “every physician, with the real and increasing threat of terrorism, must be prepared for the unknown and ready to jump into action at any moment” should there be an attack (2002, p. 12). Because Frist has already indicated that the form and timing of future attacks is unknown, every chance to be better prepared must be taken. For Frist, this means that he runs to be in better shape, and thus more mentally alert, so that he can act at his fullest capabilities. He maintains that “the best way to ensure that I am working, thinking, and feeling the best that I can is exercise” (2002, p. 12). Running, he claims, “has helped me stay in fit physical shape. It has also helped me work through long and erratic hours” (2002, p. 12). Because a terrorist attack will require physicians to be mentally alert, and because the timing of such an attack could come at any time—thus implying unpredictable hours of work that must be done well and immediately—running will benefit Frist's health and his ability to respond to a terrorist attack.

This self-discipline, coupled with his continuing education, has also allowed Frist to better serve his community. Frist demonstrates that he has worked to integrate power-knowledge by writing his book When Every Moment Counts. He defines this book as an act of “public service” that will help “to equip people with the information they need to protect their families, to reduce our vulnerabilities to bioterrorism and thereby … transform the potential for panic and paralysis into national resolve and determination” (2002, p. 13). Frist thus serves himself and the public by being physically fit, mentally awake, and well-educated on the problems of bioterrorism. This coordination of self-discipline and social influence reveals the function of the care of self: It implies Frist's mastery over the body, and thus his society. Care of the self gives Frist the freedom to act in particular ways, ways that imply freedom from the threats of terrorism.

In closing his essay, Frist brings his argument into focus. Physicians are brought to identify with other agents in the war on terror, told the importance of care of the self in being an effective and agent, and tied into larger systems of governmentality. He concludes by stating:

This is an extraordinary time in the history of our nation and our profession. As members of the medical community, we are responsible for treating the victims of a terrorist attack or, in the case of bioterrorism, identifying that a terrorist attack may have occurred. This requires us to be fully prepared physically and mentally and empowered with the most up-to-date knowledge. This is how we can contribute to the war on terrorism. This is how we can serve our country. Let us do our patriotic duty. (2002, p. 13)

In this summation, Frist provides the clearest evidence of how his argument operates. The nation and the profession both have a significant interest in defending themselves from terrorism. The role of the physician in the war on terrorism is defined; physicians must minister to the victims and report that a bioterrorist attack has taken place. The role of care of the self in preparedness is briefly outlined. Physical and mental fitness, coupled with continued education, will give the physician the freedom to act in national self-defense. Moreover, this care of the self will ensure that physicians have freedom from the threat of terrorism. Finally, this coupling of freedoms requires obedience to current forms of governmentality. Patriotism, which is read to mean support for dominant modes of governmental representation, capitalist economics, and democratic ideologies, is made the final duty in the physician's care of the self. Although this conclusion may not seem like freedom from operations of power discussed under most critiques of domination, the operation of power is such that physicians can act. A critique of domination based in neoliberal principle outlining the denial of “natural” rights or in Marxist principles of exposing the connections between capital and praxis is insufficient to understand the operations of power in Frist's rhetoric. Rather, the critique of domination must be coupled with a critique of freedom to show how physicians can act in addition to ideology critique's emphasis on how physicians cannot act.

V DISCUSSION AND IMPLICATIONS

This analysis of Frist's rhetoric demonstrates how the discourse of the care of the self can be coupled with larger commitments to governmentality. Physicians' care of the self maintains the integrity of the individual body and ensures the continued operations of governmental and economic regimes of power-knowledge. Nevertheless, power does not coerce physicians into supporting these regimes. The physician acts for the physician's benefit in a way that also benefits current regimes of power-knowledge. In the process of subjection, the physician is not repressed; the physician is invited by Frist to help produce that subject position and then to act within that subject position. The discourse of care of the self makes possible the position of a physician-citizen, but the physician then takes these conditions to make subjectivity possible as a mode of citizenship. That is, the power of governmentality is a form of power over the physician, but that power is then used by the physician to operationalize governmentality.

This negotiation of subjectivities—physician subject, citizen subject, and physician-citizen subject—transcends a simple act of domination. There is an ambiguous relationship between governmentality and physician power indicated by the discourse of the care of the self foregrounded by Frist. Power-knowledge is at once external to the physician-citizen subject in the forms of governance and economics and the venue by which the physician-citizen subject takes on power. Moreover, the physician's care of the self is a form of self-management that allows the physician to take part in the management of American society and, by extension, global society even as the physician is managed by these larger societies. Physician subjection, then, can be understood as an enactment of power by submission to a larger order and the care of the self to actively identify with and become part of that larger order.

Finally, this case study of one negotiation of subjectivity through the care of the self has broader implications for understanding the operations of power in medicine. Current discussions of power view power as a form of coercion. This view of medical power is compelling because it appears to stand in contrast to alternative social orders grounded in neoliberal or Marxist principles. This view, though, is incomplete because it generally fails to consider the alternative forms of repression that accompany these orders, a failure demonstrated in the twin diseases of fascism and Stalinism. If, however, power is viewed as productive through the process of subjection, the means by which medical subjects take on power as a freedom from repression and a freedom to act through power formations may be better understood. A focus on subjection through power rather than subjugation by power indicates that analysts of power in medical settings must treat power differently. Instead of the current focus on who has power over whom, researchers should consider how individuals take on power and thereby provide themselves with opportunities to act as well as the way that this assumptions of power constrains the ways in which these subjects can act. In addition to current concepts of surveillance and governmentality, care of the self may provide additional insight into how power operates in medicine. Analysts must determine the different subject positions that are offered in medical power relationships rather than assuming a priori categories of powerful physicians and powerless patients (or the reverse). In addition, critics should consider what actions people must take or beliefs that they must hold to retain fidelity to these subject positions and what actions or beliefs are proscribed. Last, when individuals within the medical system advocate new actions, beliefs, or power relationships, analysts should consider how current power-knowledge relationships are mobilized or contradicted to support the advocacy. If current studies of patients, physicians, nurses, administrators, public health workers, and social workers are reframed through the care of the self as a critical rhetoric, we no longer need to claim that medical subjects are repressed by power. Instead, a more nuanced understanding of care of the self may allow each of these subjects to more effectively employ power and slowly alter current regimes of medical practice.