ETHICS, GOVERNMENT AND SEXUAL HEALTH: INSIGHTS FROM FOUCAULT

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1 ETHICS, GOVERNMENT AND SEXUAL HEALTH: INSIGHTS FROM FOUCAULT Sarah Winch Key words: critical analysis; ethics; Foucault; sexual health The work of Michel Foucault, the French philosopher who was interested in power relationships, has resonated with many nurses who seek a radically analytical view of nursing practice. The purpose of this article is to explore ethics through a Foucauldian lens, in a conceptual and methodological sense. The intention is to provide a useful framework that will help researchers critically to explore aspects of nursing practice that relate to the construction of the self, morality and identity, be that nurse or patient related. The fundamentals of the research method of genealogy and the methods of ethics are reviewed. Using an example taken from the sexual health practice area, advice is given on how to structure data collection, incorporate interview data, avoid discourse determinism and measure resistance. Introduction Concepts drawn from the work of Michel Foucault, the French post-structuralist philosopher, have resonated with many nurse researchers over the years. Foucault examined the relationships between experiences (insanity, sickness, sexuality and self-identity), knowledge (psychiatry, medicine, criminology, sexology and psychology) and power. 1 The concepts of panopticism, the gaze, discipline and biopower emerged from his early and middle periods of work through his microphysical studies of power in prisons, hospitals and schools. 2,3 His later work involved a substantial reworking of his perspective on the state and the self. This produced his ideas on governmentality and political rationality, and enabled him to conceptualize agency and develop his method of ethics. It is this latter concept that is explored in this article. The first part draws together the many clues and hints within the broader Foucauldian literature to provide an accessible framework to assist researchers critically to explore the aspects of nursing practice that relate to the construction of the self, morality and identity. An example of how this may proceed, taken from the practice area of sexual health, is then provided. Address for correspondence: Sarah Winch, Nursing Education and Research Unit, Building 18, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Brisbane, Queensland, Australia, slwinch@bigpond.net.au # 2005 Edward Arnold (Publishers) Ltd / ne774oa

2 178 S Winch Ethics as care of the self The study of ethics, Foucault argued, was part of the study of morals that concerns actual behaviour, including reactions and the moral code governing actions. Foucault defined ethics as the kind of relationship you ought to have with yourself... and which determines how the individual is supposed to constitute himself as a moral subject of his own actions. 4 For researchers the concern is to examine how individuals govern themselves, rather than the importance of the moral code itself. 5 Moral action involves both a relationship with the reality in which it is carried out and a relationship with the self. This is not simply self-awareness but self-formation as an ethical subject. Specific moral action always refers to unified moral conduct and moral conduct always requires formation as an ethical subject. This can occur through the application of moral codes via pastoral and psychotherapeutic techniques frequently found in day to day nursing practice. Foucault identified two meanings of the word subject : subject to someone else by control and dependence, and tied to one s own identity by consciousness or self-knowledge. In this latter sense his ideas on the subject corresponded to the Cartesian notion of the self. Both meanings suggest a form of power that subjugates and makes subject to. 6 Foucault rejected the modernist ideas of the subject as an independent meaning-giving entity that is transcendent. 79 Furthermore he refused to elaborate a theory of the subject as is evident in phenomenology and existentialism. This extreme position is modified in the last phase of his work in which he reconsidered the nature of the subject and its capacity for agency in order to theorize resistance. Foucault explored the relationships that can exist between the constitution of the subject (such as the patient) or different forms of the subject (such as the mad or sane subject) and practices. He avoided starting with a theory of the subject, but rather asked how knowledge and practices were possible through discourse. For Foucault, the body is steeped in historically and culturally specific forms of power and becomes meaningful through discourse. The body is unstable and pliable, and constructed in different ways at different times. For example, sexuality comes into existence only when it is named as such within discourse. In this way, the subject is not a substance but a form, and this form is changeable. 10 The subject can be formed in a passive or active manner. The coercion of mentally ill people to constitute themselves as mad subjects within a relationship with one who declares that person as crazy is an example of passive formation of the subject. Alternatively, practices of the self that do not originate from the individual, but are suggested or imposed within a culture or social framework, are examples of active constitution of the subject and evidence of a subject s capacity to demonstrate agency. 4 In the last phase of his writing, Foucault moved to an interiority of the subject. 10 The self is still a historical and cultural phenomenon created through discourses (including practices), but these now include a domain marked out by the culture of care of the self. The ability of an individual to care for the self and fashion it according to certain requirements, or resist, involves a form of agency. That is not to say that a unified, rational, autonomous and essential self exists. Work on the self is, in a Foucauldian sense, an autonomous act requiring the use of moral and intellectual capacities to determine a course of action. 11 Technologies of the self are the ways in which we understand, develop and govern our thoughts and conduct. Specific kinds of subjects govern themselves in particular ways; for example, patients are expected to

3 Using Foucauldian ethics: a practical guide 179 behave in ways deemed socially appropriate for the patient role such as accepting and following care advice. If this does not occur, patients risk being labelled as noncompliant or nonadherent and corrective actions or sanctions are put into place. Foucauldian epistemology Foucault developed his methods in response to the issue that he wanted to study. Through his analyses of medicine, psychiatry, prisons and disciplinary practices he developed the tools to analyse discursive practices and trace the formation of disciplines while avoiding a science versus ideology perspective. These are his early genealogies. The analysis of power relations and their technologies as open strategies rather than purely sovereign forms of domination were also developed at this time. He argued that power relationships cannot exist unless the subjects are free, that is they have the possibility of resistance. If no resistance is possible and power is fixed in an asymmetrical fashion, then a state of domination exists. For Foucault the operation of power is always risky and resistance may generate refinement or adjustment of the techniques of power. The creation of new forms of power generates new forms of resistance. His later studies, less popular with nurses, and also his genealogies, involved compiling a history of moralities and incorporating the method of ethics. This enabled him to study the modes by which individuals constitute themselves as sexual subjects and investigate how persons were led to practice, on themselves and on others, a hermeneutics of desire. Although Foucauldian theory has provided a useful tool for analysis by nurses, his methods, particularly those of ethics, are less accessible. Foucault was interested in the discursive practices that form the basis of scientific discourse, particularly in the human sciences. While modernist theorists argue that knowledge and truth are able to be neutral, objective or universal, or serve as vehicles of progress and emancipation, Foucault argued that they were essential elements of power and domination. 3 These arguments about the relationship between knowledge, power and truth form a fundamental axiom of his work and underpin his concerns about conventional research methods, since he maintained that knowledge and truth were produced through discourse. He paid particular attention to the human sciences and the truths they produce about the human condition and challenged the view that the human sciences are innocent or impartial in character, arguing that some systems of discourse are more powerful than others. 12 Those that define what is normal, sane and rational behaviour, and direct and control the practices in these areas through policy and institutions, are of particular and obvious importance. Through large scale data gathering and manipulation, surveillance and therapeutic techniques, disciplines such as psychiatry, sociology, criminology and, we may add, nursing, have appropriated human subjects as objects of study and produced knowledge that has become a powerful means of behaviour modification and control. 7 It is precisely this domain with which Foucault s work was concerned, the dubious disciplines or human sciences that use conventional analyses to measure, predict and control as part of a disciplinary society interested in the management of the body at both micro and macro levels. Foucault 13 argued that the scientific method is appropriate for use in investigating the natural sciences, given their objective and concrete character. The human sciences, however, attempt to measure and authenticate

4 180 S Winch a social reality that is heterogeneous in nature, characterized by plurality, diversity and perpetual chaotic change. He argued that an ultimate, essential truth does not exist. Instead there are multiple forms of truth that can be produced in different ways. The rejection of a totalizing theory of life and truth leads logically to the rejection of an allencompassing method by which one authenticates the truth. Foucault accepted the Nietzschean idea that systematic methods are reductionist; instead, multiple viewpoints are required because knowledge is not based on facts, but affected by the perspective from which it is viewed. Foucault argued that certain types of knowledge were inscribed in a hierarchical order of power associated with science and that genealogy (a research method) was an attempt to free subjugated knowledge from that hierarchy. This type of argument is one to which many nurses working in medically dominated fields can relate. As a method, genealogy is concerned with the procedures and apparatus that produce knowledge, beliefs and so-called truth. 12 The purpose of the genealogical critique is to investigate not the ideological, but rather power/knowledge and hence truth regimes. These consist of objects, criteria, practices, procedures, institutions, apparatus and operations that produce knowledge and truth. Genealogy allows new perspectives to emerge by listening to the disqualified knowledge produced by groups that are low in the hierarchy, such as nurses and the patients they care for, particularly those from marginal populations. A genealogical analysis examines the political relevance of the past that has enabled the existence of objective conditions of the present, including both negative and positive aspects. It places an emphasis on the material conditions of discourse such as institutions, political events, economic practices and processes. Foucault 4 identified three possible axes of genealogy: first, where individuals construct themselves as subjects of knowledge in relation to truth : secondly, as subjects acting on others in relation to a field of power; and, finally, constitution of the self as a moral agent in relation to ethics. Foucauldian ethics as a method Foucault developed his method of ethics to study the history of sexuality and analysed four elements: ethical substance, mode of subjection, self-forming activity and telos. 4 Ethical substance involves the identification of the part of oneself that will form the object of moral practice. This is the part of the individual s psyche that responds to ethical judgement. The mode of subjection refers to the kinds of practices by which subjects form and exist, its deontology or theory of duty. The mode of subjection links the moral code to the self by exploring how this code attaches to individuals. Self-forming activity requires that individuals act upon themselves to monitor, test, improve and transform. It centres on the idea of asceticism or how we change in order to become ethical subjects, as seen in the practice of self-examination in Christianity, training and self-education. Telos denotes the kind of person we aspire to be when we behave morally. It is a goal or fulfilment, a theory of ends and purposes. The studies of ethics as outlined by Foucault in his genealogies of sexuality allow researchers to think otherwise about questions of ethics, morality, the self and liberation, by illuminating the historical relativity of modern-day morality. 14 The practice of nursing is a socially constructed form that requires both the nurse and the

5 Using Foucauldian ethics: a practical guide 181 patient to adopt particular modes of behaviour, training, self-reflection and monitoring. This transformation of the self (either into a nurse or a patient) is then reinforced at a political level through policy, agents and authorities. The value of an ethical analysis of this area lies in the illumination of the moral character for both nurses and patients, and also explicates some of the problems in resisting politically prescribed caring or patient roles. The very nature of nursing means that nurses in all practice areas can find themselves trying to develop or instil codes of behaviour and morality in their clients. The practical application of Foucault s methods of ethics raises a number of issues in relation to research. First, Foucault said little on measuring the first element, that of identifying the ethical substance. Rabinow 15 claims he is thought to be referring to the Nietzschean notion of an unconditional will to truth. Nevertheless, this lack of explication is overcome somewhat by referring to examples such as those given by Foucault in his study of Christianity, where desires become the ethical substance for Christians. 16 It is also difficult to separate the four elements of ethics. These problems are overcome somewhat when one considers Rose s 17 study of contemporary personhood, which combined Foucault s methods of genealogy and ethics to conduct a genealogy of subjectification. Rose 17 defined subjectification as all those heterogeneous processes and practices by means of which humans come to relate to themselves and others as subjects of a certain type. A genealogy of subjectification focuses directly on the practices that situate individuals within specific regimes of the person. There is similarity in Rose s approach (as he acknowledges) to Foucault s method of ethics without specifying or separating the actual elements Foucault uses in his analysis. The value in using Rose s approach is that it combines the broad elements of governance (problematizations, technologies of government, authorities, and political and economic strategies) and practices of the self (technologies of the self or the way in which individuals control and shape their own conduct). Making the dataset A framework identified by Foucault 18 and streamlined by Dean 19 identifies components that may be used to map how a particular discourse came into being, how subjects were selected and objectified, and how the conditions of the present and the ontological status of participants emerged. These components are training, relevant forms of expertise, systems of classification, administrative principles, laws and juridical practices, theories, strategies, programmes of governance and their targets, aims, ideals and effects, and agents and authorities. Using this approach, written records, including policy documents, laws, archival material, institutional reports, and training schedules, need to be collected. Data should also be drawn from practical texts that provide rules, opinions and advice on how to behave in a certain fashion. These texts are themselves objects of a practice in that they are designed to underpin everyday conduct. They are mechanisms that enable individuals to question and shape their own conduct, and to become ethical subjects. 19 Generally, a pure Foucauldian analysis would not gather data by interview or survey methods. Foucault 20 argued that large-scale quantitative data that are able to be generalized because of their statistical validity are an example of powerful discourse,

6 182 S Winch high up a hierarchy, capable of dominating and subjugating other power/knowledge discourses. Qualitative methods can be just as problematic as quantitative methods in that, as Armstrong argues, they have created the objects which they have claimed to have found: a study of stigma created stigma, a study of coping created coping, a study of cognition created cognition. 21 For Armstrong, traditional qualitative methods are the means by which a new sociomedical gaze of the population takes place. Whereas quantitative methods trace the patterns of populations in a broad normalizing fashion, qualitative methods enquire into the subtleties of subjective experience. Qualitative methods can be seen as a mechanism by which the subject can confess and be constituted as an experiential object. Now the subjects speak where previously they were unheard; their personal experiences are collated to instigate new categories and regimes. The difficulty for researchers is that unstructured interview data can be useful, particularly when trying to measure resistance to power regimes affecting marginalized patients and nurses. I believe that three arguments can be advanced to justify the inclusion of interview data in a dataset. First, while agreeing with Armstrong s logic, taken further it can also be applied to Foucault s genealogical and archaeological research, where new subjects and objects are able to be identified through his various genealogies. Secondly, if only documentary data are used to identify subject and object positions and power knowledge matrices, then the possibility of a purely structural explanation (of little use to nurses) is increased. In order to measure localized resistance occurring in current power/knowledge configurations, hearing the experiences of the subjects and objects (if possible) is important. Finally, in order to identify whether resistance is possible at all, that is to clarify whether the situation is one of power or of domination, it is critical to be able to assess the level of agency or the capacity of individuals to resist discourse. In contemporary studies this may be achieved through careful interviewing. It is possible to conceive that participation in small-scale, localized research may be used as a form of resistance by participants as well as a method of measuring levels of resistance. It is also a method of avoiding discourse determinism, where documentary discourse solely determines the explanation. If researchers decide to include interviews for these reasons, they need to ensure that the interviews are unstructured. When transcribed, the interviews can become texts but should not be coded or categorized as with many other forms of qualitative analysis. Data analysis Data can be analysed in several complementary ways and presented in the form of an analytical grid that proceeds along two axes. These axes are the political (governance of nurses, nursing, health care through political, economic and social means) and the ethical (governance of the self either as a nurse or as a patient through the cultivation of the ethical practices required). Using Dean s 22 typology for an analysis of government, these are forms of visibility, distinctive ways of thinking about the nurse or patient, practical rationality (expertise and know how), and methods of subject formation. For example, an analysis of the role of the school-based health nurse in shaping teenage sexual health behaviours could proceed as follows. The first genealogy needs

7 Using Foucauldian ethics: a practical guide 183 to examine the practices of the government of teenagers and one of the authorities that govern them, such as the school-based health nurse. The analysis needs to consider the conditions of possibility that enable the production and subsequent government of these groups. This is achieved first by assembling the critical elements that establish when and how it was first possible to speak about the teenager within a sexual context and how this became established in wider historical, economic, social, political and institutional frameworks using the documentary data detailed previously. In this way it is possible to trace how teenagers became visible within sexual health discourse. Critical elements involved in the production of thought about sexually active teenagers are systems of classification, administrative principles, laws and juridical practices, theories, strategies, programmes of governance, and their targets, aims, ideals and effects. In addition, this genealogy outlines the practical rationality of school-based sexual health by identifying agents and authorities and forms of expertise such as nursing. Continuing with the example, the second genealogy also considers the practical rationality involved in school-based sexual health, but this time from the students perspective. It focuses on the practices of the body and the self that lead students to recognize themselves as sexual beings and possible patients by constructing what Rose 17 has termed a genealogy of subjectification. It examines methods of formation for the sexualized student subject. Davidson 23 argues that a method for constructing a history of subjectivity is to identify the transformations that are required by the self within a particular domain. These are assisted by relationships with others in the form of pedagogy, advice about conduct, spiritual direction and prescriptions on how to live life. In this analysis, attention needs to be paid to how students identify as sexual beings and develop or attempt to develop the capacities, attributes and orientations that make up their sexual identity. The genealogies can be constructed via Foucault s methods of eventalization and problematization. Eventalization 24 examines key events that serve as markers for the transition, continuity or rupture of a discourse. These events are identified and analysed according to their components and the multiple processes that have enabled their formation. This is achieved first by looking for a breach of self-evidence : that is, establishing that events are not natural, or obvious, or part of a historical constant, or an anthropological trait. The second part of this analysis involves looking for multiple causes. This procedure explores the connections, supports, blockages and strategies that have established what is seen as self-evident, natural or necessary. Analysis thus progresses along two axes, a breakdown of the processes that constitute an event and a concomitant assembling of their external relationships of intelligibility. This then leads to an increasing polymorphism of: (i) the elements that are brought into relation (ii) the relationships described and (iii) the domains of reference. 25 In the case of this example, which traces the emergence of sexualized teenagers, the nature of sexual conduct for teenagers as a natural and historical event is questioned. Elements brought into this are the concept of a teenager, the school, the nurse, the student and the family. The relationships between these are multiple and will likely have been problematized differently across time. Problematizations occur when some aspect of the government of conduct is called into question 22 and also in particular regimes of practices (in this example sexual health care) and of government (in this case of teenagers). Rose 17 contends that problematizations occur according to where, how and by whom the behaviour is being

8 184 S Winch judged and through the definition of phenomena, measurement and enumeration. Similarly, these are key elements in the governing process because they allow for evaluation, judgement and review. Broadly, problematizations may be classified as discursive, governmental and ethical. 14 Discursive practices may problematize domains of objects (for example life, language) within the production of knowledge; governmental practices problematize certain objects of knowledge (age and sexual health), and ethical practices problematize the formation of the self in certain knowledges as a practice of freedom (prohibition, renunciation, asceticism). A further step: measuring resistance It is important in any Foucauldian analysis to measure resistance. Speaking about the relationships of power, Foucault 26 argued that power cannot exist unless the subjects are free; that is, they have the possibility of resistance. Resistance, in effect, is the result of human freedom. Autonomy can then be understood as an ability to govern one s own actions. 25 For Foucault, 27 resistance exists in as many diverse forms as power does, and is more effective when it is directed at a specific technique or instance of power, rather than at power in general. The creation of new forms of power engenders new forms of resistance. If no resistance is possible and power is fixed in an asymmetrical fashion, then a state of domination exists. This refers to a particular form of power that is relatively stable and hierarchical and can be seen in sexual, economic, social and institutional forms. In this situation individuals have a poor capacity for resistance, 28 although collective resistance may still be organized through a revolution or a strike. It is possible to measure resistance in the example considered here. Initially, it is important to identify whether a state of resistance or domination exists between students and others in the caring relationship. This is achieved by assessing the capacity for the students to be free and/or autonomous and assessing the impediments that may infringe on that capacity. Formal and informal patterns of resistance can also be elicited and this is where the data from the texts created from the student and nurse interviews are vital. The interviews can ascertain how closely (if at all) teenagers and nurses identified with the discursive positions that have been created through policy. In this way any personal forms of resistance can be identified. In addition, modern human services policy often has inbuilt mechanisms of resistance and these would need to be assessed. Conclusion Foucault s perspective on ethics has been explored in this article in a conceptual and methodological sense, both theoretically and using a practice based example. This type of research is labour intensive and complex, but it has the potential to illuminate the role of nurses as agents, subjects and objects in a practice field rich with socially constructed moral precepts and codes. The value of this type of analysis is the highly analytical view of practice it provides. This view links the minutiae of nursing work with formation of identity, the monitoring of conduct, and fashioning of behaviour within broader historical, social and political processes and institutions.

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