technogovernance: evidence, subjectivity, and the clinical encounter in primary care medicine
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Social Science & Medicine 62 (2006) 1022–1030
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Technogovernance: Evidence, subjectivity, and the clinicalencounter in primary care medicine
Carl May�, Tim Rapley, Tiago Moreira, Tracy Finch, Ben Heaven
Centre for Health Services Research, University of Newcastle upon Tyne, Newcastle upon Tyne, NE2 4AA, UK
Available online 12 September 2005
Abstract
Technological solutions to problems of knowledge and practice in health care are routinely advocated. This paper
explores the ways that new systems of practice are being deployed as intermediaries in interactions between clinicians
and their patients. Central to this analysis is the apparent conflict between two important ways of organizing ideas
about practice in primary care. First, a shift away from the medical objectification of the patient, towards patient-
centred clinical practice in which patients’ heterogeneous experiences and narratives of ill-health are qualitatively
engaged and enrolled in decisions about the management of illness trajectories. Second the mobilization of evidence
about large populations of experimental subjects revealed through an impetus towards evidence-based medicine, in
which quantitative knowledge is engaged and enrolled to guide the management of illness, and is mediated through
clinical guidelines. The tension between these two ways of organizing ideas about clinical practice is a strong one, but
both impulses are embodied in new ‘technological’ solutions to the management of heterogeneity in the clinical
encounter. Technological solutions themselves, we argue, embody and enact these tensions, but may also be opening up
a new array of practices—technogovernance—in which the heterogeneous narratives of the patient-centred encounter
can be resituated and guided.
r 2005 Elsevier Ltd. All rights reserved.
Keywords: Technogovernance; Primary care; Medical knowledge; United Kingdom
Introduction
Recent sociological accounts of technological change
in medicine—whether they review apparently global
developments in the domain of technoscience (Clarke,
Mamo, Fishman, Shim, & Fosket, 2003; Webster, 2002),
or more specific developments in genetics (Franklin,
2001), visualisation (Waldby, 2000), or the internet
(Nettleton, 2004)—have all been forced to struggle, in
one way or another, with the problematic interactions
between two kinds of medical knowledge. The first of
e front matter r 2005 Elsevier Ltd. All rights reserve
cscimed.2005.07.003
ing author. Tel.: +44191 222 7046;
2 6043.
ess: [email protected] (C. May).
these is experiential qualitative knowledge rooted in
clinical experience and worked out in the everyday
clinical encounter, and the second is experimental
quantitative knowledge derived from population studies,
randomised controlled trials and meta-analyses, and
worked out through the production of different kinds of
clinical guidelines for practice.
In the UK, the interaction between these two ways of
thinking about the ways that medical knowledge
informs practice has often been framed in terms of a
contest between individual clinical autonomy and a new
field of evidence based medicine, and this has been
represented both in studies of experiences of clinical
practice (Summerskill & Pope, 2002), and in studies of
doctors’ perspectives on the interpolation of newly
d.
ARTICLE IN PRESSC. May et al. / Social Science & Medicine 62 (2006) 1022–1030 1023
codified ‘evidence’ into their everyday work (Armstrong,
2002). At a macro-level the shift to evidence-based
medicine has been understood in terms of the play of
power through the intervention of the state and its
relatively autonomous agencies to regulate medical
practice (Harrison, 1996), which in turn acts as a key
element of policies and practices around the ‘moder-
nisation’ of the National Health Service (Harrison,
1999). This view parallels a growing recognition of the
emergence of steadily more sophisticated and interven-
tionist mechanisms of state intervention and regulation,
what Moran (Moran, 2002) has termed the ‘transforma-
tion’ of the regulatory state from ‘government by
command into uncoupled systems of self-steering’
(p.391). These ‘uncoupled systems’ themselves form
mechanisms of self-surveillance and governance (Daly,
2003), in which regulatory authority is delegated
downwards into different public sector bodies and
responsibility for meeting the demands of new struc-
tures of governance is diffused through networks of
active management rather than traditional patterns
of bureaucratic administration (Kelly, Mulgan, &
Muers, 2002).
Political struggles over the status of evidence-based
medicine (EBM) are only one element of a complex
arrangement of shifts that are currently taking place in
the British health care system and which frame the
production, mediation and effects of knowledge about
health and health care in relation to individuals and
groups. In this paper we argue that these struggles are
about more than clinical autonomy and managerialism,
but also represent struggles over what kinds of
experiences and knowledge patients are authorised to
bring to the clinical encounter, and how these are made
to count.
Our analysis focuses on the apparently routine
practices that surround the management of chronic
illness in primary care, for this is the field in which
contradictory tendencies of subjective engagement and
aggregated abstraction are being worked out. We call
upon a range of theoretical dispositions, from perspec-
tives informed by interactionist (Strauss, Fagerhough,
Suczek, & Wiener, 1997) and Mertonian ‘middle-range’
theories (Reiser, 1978) of the interaction between
technologies and social practices, to more recent
theoretical positions in which technologies and social
practices are understood to be woven together in the
most intimate way (Heath, Luff, & Svensson, 2003;
Timmermans & Berg, 2003a), and theories of discourse
and its production in critical psychology (Mather, 2000).
The paper is divided into four sections. We begin with
the problem of patient-centredness—a crucial recent
ideological move in medicine—and then explores its
consequences in debates about informed and shared
decision-making in the clinical encounter. The focus
then shifts to practices of production of EBM and its
mediation in the clinical encounter. Finally we point to
the emergence of new technologies and systems of
practice which mediate between patients and health care
providers and which reconstruct the patient as a
minimum data set. At the heart of our analysis is a set
of problems about power, knowledge and subjectivity,
and the ways that policies of modernisation bind new
technologies into a new way of framing health care
practice which we call technogovernance.
Problem of subjectivity
A problem for medicine as a general field is what to do
with the patient’s subjective experience of illness, and
how to connect it with medical knowledge and practice.
Since the 1800s, medicine has focused primarily on
underlying organic pathology: shifting attention away
from the patient’s expressed symptoms and onto clinical
signs—initially attending to organic processes and
disease states, but moving steadily towards more
microscopic analyses of the body (e.g. genetics). Jewson
(Jewson, 1976) has characterised this as a changing
‘cosmology’ of medical practice, in which the sick person
disappeared, to be replaced by the diseased organ or
lesion; while Armstrong (Armstrong, 1983), following
more directly from Foucault (Foucault, 1973), has seen
in this reductionist impulse the emergence of a political
anatomy of the body. This notion is particularly evident
in accounts of the professional socialisation of medical
students, which show how ‘proper’ medicine comes to be
seen as biological in its focus (Becker, Geer, Hughes, &
Strauss, 1961; Good, 1994), the patient’s account of
experienced symptoms being secondary to the doctor’s
authoritative diagnosis based on revealed pathological
signs (Hunter, 1991; Atkinson, 1995). Attempts to
expand the conceptual ambit of medicine have foun-
dered (Armstrong, 1987) as organic pathology is
concrete—it is both a ‘fact’ and a ‘thing’ to be worked
on, and thus deceptively seems both asocial and
atheoretical. The world beyond the body is inherently
and obviously social and thus subject to interpretation.
So, when the patient’s subjective experience is consid-
ered, it is often framed as a medicalised problem: for
example, the psychological consequences of surgery
(Jagmin, 1998; Peerbhoy, Hall, Parker, Shenkin, &
Salmon, 1998); or ‘quality of life’ measures that might
explain differential recovery rates (Bowling, 1991). More
complex elements of the patient’s subjectivity can be
delegated by medicine to nurses, who have worked hard
to claim the emotional labour of patient care for
themselves (Davies, 1995).
The reductionist impulse that characterises much
medical work presents a particular problem for
General Practice, which claims a much wider vision of
the patient (Neighbour, 1987). The reductionist medical
ARTICLE IN PRESSC. May et al. / Social Science & Medicine 62 (2006) 1022–10301024
model has poor practical utility in three areas of general
practice:
�
the management of chronic illness, where the focus ison maintaining and adjusting medical management
according to the social character of the patient’s
world (e.g. diabetes, asthma, arthritis, congestive
heart failure);
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diffuse symptoms that derive from the social andpsychological character of the patient’s world, that
tend to be considered inappropriate for hospital-
based investigation and treatment (e.g. low grade
depression, fatigue, medically unexplained symp-
toms, chronic low back pain, gastro-intestinal
discomfort);
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preventative health care, where the focus is onidentifying and motivating ‘at risk’ and ‘risky’
patients to change behaviours and habits prior to
the onset of any organic or psychosocial pathology
(e.g. alcohol, diet, hypertension, diabetes, exercise).
While hospital medicine may have put the subjectivity
of the patient to one side, doctors in general practice
have struggled to make sense of it since before the First
World War (Cox, 1950). In the intervening period,
psychological theories have been formed around pro-
blems that medicine finds compelling, and these have
framed medical thinking about the consultation in
important and powerful ways after the 1950s (Bower,
Gask, May, & Mead, 2001). Over the past 30 years, a
series of key conceptual and empirical interventions
have challenged the doctor-centred model of medical
consultation, emphasising patient-centredness in medical
practice (May & Mead, 1999). Proponents of the latter
stress the therapeutic value of interactional work
through which the patient’s subjectivity may be both
understood and engaged (Platt et al., 2001).
It is important, however, to relate these conceptual
moves to wider structural and policy shifts in the
organisation of health care. Changing social and cultural
concerns, reflected in the emergence of new kinds of
interest groups during the 1970s, supported a shift away
from medical paternalism (Bury, 1998; May, 1992). The
shift from a paternalistic doctor-centred model of the
clinical encounter, to an apparently more democratic and
patient-centred encounter involves the reconfiguration of
ideas about what the work of a clinical encounter is. The
doctor-centred model relied on the epistemological
authority of medical knowledge and practice embodied
in the individual, responsible, doctor (Parsons, 1951).
In the doctor-centred model of family medicine, the
objective of the clinical encounter was the conversion of
subjective experiences of illness, into objective patholo-
gical categories through the discovery (within the
patient) of pathology that accorded with the nosology
of clinical medicine. Once that diagnostic moment was
achieved, then judgments about prognosis and manage-
ment could commence. But more recent modes of
medical thought also rely on these nosological facts
(Osborne, 1998). The patient is still required to form a
narrative of experience of illness, while the doctor
translates this into pathological models. At the point
at which general practice, under the influence of Balint
and his followers (Balint, 1957), stepped beyond the
reductionist biomedical model, to claim a psychother-
apeutic sensibility for the consultation, and the possibi-
lity of a therapeutic alliance—thus opening the way for a
patient-centred clinical encounter—then individual doc-
tor-patient encounters became, progressively, more
inclusive (Gothill & Armstrong, 1999). Understanding
the ‘whole’ patient could be achieved in a longstanding
relationship, in which consultations were specific epi-
sodes of conceptualisation, through particular ways of
reasoning about the problem. In the shift to patient-
centredness, and its associated notions of empowerment
and enablement, real problems emerge in the clinical
encounter (Salmon & Hall, 2004).
The doctor-centred model of practice made no claim to
enrol patients as anything more than the focus of medical
attention. But the impulse to patient-centred practice
does, and it has involved the production of specific
technologies by which this can be achieved. Individual
relations between doctor and patient are now conceived
as a technical problem of practice, which may be resolved
by reskilling the doctor. These skills maybe identified,
studied and audited—diagnosed, even—through the use
of observational instruments (often applied to recordings
of consultations) and questionnaires directed at patients
and peers. Here, ideas about communications skills;
patient-centredness; enablement and empowerment (Ho-
wie et al., 1999); and notions of quality are available to be
mobilised and enforced by state actors and professional
elites as a means of adjudicating on the conduct of the
doctor. Central to this is the quantitative measurement of
the behaviours and interactions to be found within
doctor-patient relations, and the assessment of their
effects. Individuated autonomy is governed and regulated
by these new systems of observation, in which modes of
reciprocal surveillance are mobilised and patients are
enrolled to make judgments about the doctor’s actions.
The assumption is that better communication between
doctor and patient has positive health outcomes, and that
a patient-centred consultation increases patient satisfac-
tion, and that a ‘health gain’ follows from this (Mead &
Bower, 2000).
Negotiating medical knowledge
The shift to patient-centredness opens up heterogene-
ity: patients are no longer construed as specific instances
ARTICLE IN PRESSC. May et al. / Social Science & Medicine 62 (2006) 1022–1030 1025
of a disease to be locally negotiated, nor are they passive
recipients of individualised and authoritative expertise.
Instead they are now conceptually organised as local
negotiators of a problem, able (and expected) to make
choices about its management, express subjective
experiences and wants, and to adjudicate on the quality
of the care they receive. All of this is expected to take
place in condensed time and space—for the average
length of a consultation in British general practice is
somewhat less than ten minutes (Howie, Porter, Heaney,
& Hopton, 1991). The move towards a patient-centred
consultation—in which patients are set up as active
participants in the construction of the problem and in
making choices about its resolution—requires that this
knowledge is made explicit. This has important implica-
tions for the epistemological authority of medical
knowledge and practice, which cannot now rely
completely on either its embodiment in the doctor or
in the doctor’s individual clinical interpretation of
symptoms, signs and their meanings. The point that is
central to this is the sense in which the clinical encounter
has been reframed as a set of negotiations in general
practice’s grand narratives of patient-centredness, since
the very presence of these negotiations assumes a degree
of epistemological authority for the patient’s story.
Crucial to this has been the ways that medical knowl-
edge has been restructured by the development of
professional expertise specifically concerned with the
evaluation of medical therapies and the emergence of
EBM. EBM can be seen as the consequence of a process
that started with the consolidation of the randomised
clinical trial as research technique in medicine—in the
1950s in the US (Marks, 1997) and in the 1970s in the
UK (Harrison, 1996)—and later with the establishment
of the regulatory sciences of health technology assess-
ment and quality improvement studies in the 1980s.
There is now a very large literature that stems from
medical research and health technology assessment, and
that reflects contests about the effectiveness of health
care practices. Such contests are manifest, as Timmer-
mans and Angell (Timmermans & Angell, 2001) show,
in the ways that evidence based practices are reformu-
lating the kinds of uncertainties that doctors encounter
in their everyday practice; and in the configuration of
what they call ‘research based uncertainty’, the hesita-
tions arising from evaluating the worth of the ‘evidence’.
In clinical practice, the ambiguous status of this
population-based medical knowledge does not allow
for a shift towards a procedural mode of diagnosis and
treatment—the ‘cookbook medicine’ of EBM’s critics.
Indeed, although experimental studies seem to show that
guidelines are valuable and useful to doctors (Grol et al.,
1998), and that they guide practices around particular
conditions, there is also evidence that, as a type of
standardisation procedure for clinical work, guidelines
run into difficulties in the individuated encounter
between doctor and patient (Summerskill & Pope,
2002). The collectivised expertise that emerges through
EBM does not seem to ‘fit’ well with the exigent
practices of doctors—it is mathematical rather than
experiential—and it seems to fit poorly with the
individualised heterogeneous accounts and moral re-
sponsibilities that sit within the ‘patient-centred en-
counter’.
The reliance of EBM on the results of clinical trials is
a problem too: these are often seen as a ‘gold-standard’
because of their formal, standardised and replicable
methods, and because they are amenable to collective
assessment and re-analysis through procedures of
systematic review and statistical meta-analysis. The
problem here is not so much the separation of EBM
from practice—but, as Upshur (Upshur, 2001) observes,
the fetishisation of randomisation as scientific method
rather than statistical technique. It is the latter that gives
EBM its epistemological authority, but problems of
accountability also arise—for the methodological pro-
blems of trials and their meta-analysis are well under-
stood (Timmermans & Berg, 2003b). So, the most potent
criticism of EBM within medicine is an epistemological
one, although derived from an understanding of the
everyday difficulties that attend the production of
experimental knowledge (Miles, Bentley, Polychronis,
& Grey, 1997).
The shift to patient-centredness raises problems of
subjectivity, heterogeneity and narrative authority in the
clinical encounter. EBM is one kind of institutional
response to this, because it makes explicit the knowl-
edge, which forms a point of departure for treatment
and management decisions. But it also requires a set of
practices of integration that enable clinicians to draw it
into everyday practice. These practices are both formed
and made visible in recent debates about shared
decision-making in primary care. Here, the emphasis is
on both doctor and patient expressing preferences, and
negotiating an agreed course of action on the basis of
codified clinical evidence. Work has therefore proceeded
that explores the interactional skills and contextual
difficulties that attend these shared negotiations (Barry,
Stevenson, Britten, Barber, & Bradley, 2001; Elwyn et
al., 2001), the problems that emerge within such
negotiations, and their attempted resolution (Gwyn &
Elwyn, 1999). Ideologically, shared decision-making is
located completely within the field of patient-centred-
ness. Bensing (Bensing, 2000) asserts that, ‘the ultimate
goal is the mutual tuning of the doctors’ and patients’
agenda, and reaching a decision both parties feel
comfortable about’ (p. 21). Even so, there are significant
conceptual difficulties about establishing what a ‘shared
decision’ is constituted by in practice, and about how it
may be practically achieved (Stevenson, 2001). As a
technique of integrating evidential and experimental
knowledge about treatment and management decisions,
ARTICLE IN PRESSC. May et al. / Social Science & Medicine 62 (2006) 1022–10301026
such a model of practice is vulnerable to contests
between the epistemological authority of the subjective
construction of the patient’s life-world, and the episte-
mological authority of the doctor’s knowledge. To
sustain the latter, while still viewing the patient’s
subjectivity inclusively, some new intervention is needed.
Calculating and presenting risks
To the epistemological and practical challenges we
have described above, we now need to add another
problem. This is that much of what is now at issue and is
not so much the prognostic calculation embedded in the
management of a disease, but rather the calculation of
risks and effects—deploying knowledge derived from
large trials, or from systematic reviews and meta-
analyses—and translating this knowledge about collec-
tivities into an individual plan for a specific patient.
One of the possible embodiments of this problem are
decision-support tools, or decision aids, seen as capable
of being a ‘supplement’ to the existing communication
with the patient (O’Connor et al., 1999), able to ‘help
people make deliberate and specific choices’ about their
treatment options and the possible range of outcomes of
these. This new technology—of enrolment into a
decision-making process—takes a range of possible
forms, including interactive computer programs, audio-
tapes, pamphlets, and group presentations. All of these
are intended to move beyond the ‘passive’ printed
educational material available for patients, and to
integrate them into an active decision-making process
in new ways. Some are intended for use within the
everyday doctor–patient interaction, some outside it. All
are intended to make possible some kind of systematic,
multi-factorial, approach to an ‘optimal’ decision.
Elwyn and Charles (Elwyn & Charles, 2001) outline
the stages and competences of involving patients in
decisions:
[b]oth professional and patient share information
with each other. At a minimum the professional
informs the patient of ‘all’ the information that is
relevant to making the decision, for example,
treatment options and their benefits and risks. The
patient reveals personal information to the profes-
sional, for example, lifestyle, preferences for different
health states, and issues of importance regarding
quality of life (p. 120).
Importantly, the doctor should share evidence-based
information in just the format that the patient prefers.
This offers an individualised context for evidence-based
patient choice, but crucially, the means of delivering it in
a workable way is increasingly found in information
technologies. These can handle information in struc-
tured ways, calculate risks, and specify outcomes. Most
importantly, non-human actors make it possible to
sustain the epistemological authority of both the
doctor’s and patient’s position, by interposing a set of
values defined elsewhere as the structure of the decision-
making process. So, working through a decision-making
tool—for example, a computer program that permits
doctor and patient to make decisions about treatment
choices for people at risk of stroke (Thomson et al.,
2000), or a system that directly connects the doctor to
sets of updated clinical guidelines and authoritative
knowledge (Rousseau, McColl, Newton, Grimshaw, &
Eccles, 2003)—seems to permit a new kind of clinical
encounter, where engaging with a non-human actor
allows them to jointly share uncertainty. In such
systems, the patient’s subjective engagement with
chronic illness is reframed as a set of limited preferences
that can be mechanically elicited, and then acted upon.
As O’Connor (O’Connor, 1999) notes,
Through the development of information technology,
information that once ‘‘belonged’’ to professionals is
now widely accessible. And from work of evidence-
based practice, information about clinical interven-
tions previously ‘‘hidden’’ away in journals on library
shelves has been re-analyzed in systematic reviews
and meta-analysis and repackaged into clinically
relevant formats. Thus the tools to allow patients to
be real partners in deciding the course of their health
care are available and may soon become the norm
(1999, p.5).
It also interposes an external epistemological author-
ity into the consultation: the values and choices involved
have been constructed elsewhere, in relation to an ideal-
type patient, and ideal-type evidence. What this move
also makes possible is the re-situation of heterogeneity
outside of the centre of the consultation: the key account
is that which is formed around the decision-making tool.
All other aspects of the patient’s subjectivity may be
reframed to be secondary to this.
While information technologies intervene to reorga-
nise the subjectivity of the patient, and to respecify the
ways that this can be worked out, new ‘fields’ of
medicine and health care are also indicated in the form
of ‘telecare’ and ‘e-health’ (Cartwright, 2000; Nettleton,
2004). While the web makes possible not only access to
distributed information and expertise but also new
communities in which identities and subjectivities are
negotiable (Nettleton, 2004), in the emerging field of
telecare new methods for decoupling patients’ subjectiv-
ities from clinical encounters are made possible. Telecare
systems for monitoring the health status of people with
chronic and degenerative diseases are now widely
available (Glueckauf & Ketterson, 2004; Louis, Turner,
Gretton, Baksh, & Cleland, 2003). These devices
ARTICLE IN PRESSC. May et al. / Social Science & Medicine 62 (2006) 1022–1030 1027
measure physiological status and other data, present this
data to individual service users, and transmit it for review
by service providers using either mobile or conventional
telephony. They promise accurate self-surveillance, (which
may lead to improvements in compliance with treatment
regimens and users’ expertise in self-care); and remote
monitoring of individual health status by service providers
to enable early intervention and reduce hospital admis-
sions. Moreover, they act in two ways to secure a specific
version of chronic illness management. First, by setting
objective parameters for an exacerbation event—for
example, hyperglycaemia in diabetes, or blood oxygena-
tion in chronic obstructive pulmonary disease, (Mair,
Wilkinson, Bonnar, Wootton, & Angus, 1999; Montori et
al., 2004)—they act as gatekeepers, placing a minimum
data set about the patient in front of the patient’s own
account. Second, as automated devices, communicating
with a base station or call centre they act to form distance
between service users and service providers (May, Finch,
Mair, & Mort, 2005). The distal patient that emerges
within the field of telecare poses additional challenges for
the management of subjectivities within medicine. Much
of this new field of practice is about shifting medicine and
health care away from hospitals and back into the local
community—its proponents make claim to the potential
benefits of moving specialised hospital based knowledge
and practice back into the community through the use of
information technologies.
Technogovernance
A central feature of contemporary modes of govern-
ance is distributed accountability (Newman, Barnes,
Sullivan, & Knops, 2004). In this context, the shift from
doctor-centred to patient-centred individualizing ap-
proaches to the clinical encounter and to shared
decision-making practices within it can be seen a
political, as well as a clinical, move. But the shift to
patient-centred practice brings with it a problem, this is
found in the priority that is given within it to the
patient’s subjective narrative of illness experience, and
which we have framed as a problem of heterogenity. So,
far from intervening directly in the body, or imaging its
interior, these shifts are concerned with framing the
structure and direction of the engagement between
doctors and patients. These are governmental technol-
ogies, intended to guide conduct and so to structure
work. It therefore seems more appropriate to describe
them—following Foucault’s (Foucault, 1986) notion of
‘governmentality’—as ‘technogovernance’. We have de-
scribed three impulses at work:
1.
The codification and representation of objectiveexperimental knowledge (EBM) about populations
is a point of departure for shared decision-making.
This respecifies individualization by disconnecting
the patient’s experience from knowledge about
effectiveness of treatment.
2.
Non-human actors can be incorporated into theclinical encounter to decouple experience and man-
agement. New technologies (in the form of guide-
lines, protocols, and decision-making tools) may be
employed to structure the range of possible decisions
in the clinical encounter itself. The patient’s (and to a
lesser degree, the doctor’s) subjective experience is
therefore separated from decisions about the proper
management of a problem.
3.
New practices and technologies are emerging thataim to distribute accountability beyond the clinical
encounter, and frame the patient as both self-
manager and the source of a minimum data-set
about clinical condition. The first of these firmly
relocates subjectivity in the life-world of the patient,
the second abstracts from the life-world only that
data that is necessary to determine the trajectory of a
chronic illness, analyses this within parameters that
objectively define the point at which health care
interventions might be required, and alerts an
appropriate authority.
The net effect of these shifts is to bring into play new
practices of governance, in which intermediaries are
deployed to discipline and frame the individual sub-
jectivities of both patient and doctor, and these practices
of technogovernance act to distribute accountabilities
and to survey their products. In parallel to this is a
steady trend towards measuring the effects of distributed
accountabilities. So informatics interventions—whether
they elicit preferences, guide clinical practice, or permit
the remote monitoring of the chronically ill—permit not
only a decision, a programme of management, or
parameters of access, but also have embedded means
of adjudicating and reporting on those decisions to
others. They thus act to effect reciprocal surveillance,
and in doing so open the path to a much wider network
of accountabilities.
None of the impulses that are found in the field of
technogovernance are final achievements, for some are
bitterly contested, and all are riven with internal
tensions. Patient-centredness is a problem (Mead,
2002); evidence-based medicine engenders difficulties in
the clinical encounter and is contested as a form of
knowledge in itself (Summerskill & Pope, 2002); shared
decisions are rarely formed in non-directive encounters
(Stevenson, Barry, Britten, Barber, & Bradley, 2000); the
distal patient presents medicine with massive problems
of interpretation and action (Mort, May, & Williams,
2003); and the virtual world of ehealth is hard to
interpret and enact (Eysenbach & Diepgen, 2001). The
implication of this is that technogovernance is itself
ARTICLE IN PRESSC. May et al. / Social Science & Medicine 62 (2006) 1022–10301028
profoundly unstable, because its specific elements em-
body these tensions both in their production and their
practice.
In his reworking of the Greek myths, The Marriage of
Cadmus and Harmony, Roberto Callasso (Callasso, 1978)
offers a powerful reminder that apparently specific
histories have multiple beginnings. Our analysis sets out
one such history—how, over a period of two decades,
problems of epistemological authority have emerged in a
particular branch of medicine. But it also suggests
continuity. The problem of objectification in medicine, to
which the patient-centredness movement (and the ‘biop-
sychosocial’ model that underpins it) is a response, brings
in its wake a problem of whose knowledge counts in the
clinical encounter when this focuses on the trajectory of
chronic illness, diffuse problems, and hidden risks. It does
so by a labour of division that makes heterogeneity, and
which makes the clinical encounter itself hard to manage.
The systems of practice embedded within technogo-
vernance constrain heterogeneity by framing the ‘pro-
blem’ of the encounter in different terms—shifting the
question away from localised authority towards dis-
tributed information. These are hybrid medicines, not
only because they consolidate interdependencies be-
tween humans and non-humans, but also because, in so
doing, different, apparently contradictory versions of
medicine are brought together in the clinical encounter.
In these hybrid medicines, the symbolic drama of the
consultation, and of the clinical actions within it, may
now have a second, on-screen script in which the facts of
the case are framed against information about a
multiplicity of cases and possibilities.
Acknowledgements
We gratefully acknowledge the financial support of
the Alcohol Education Research Council (Grant
APP41/2001); Department of Health (Grant ICT 2/
032); Economic and Social Research Council (Grants
L218 25 2067 and RES000270084); European Commis-
sion; National Institute of Clinical Excellence; and
Wellcome Trust (Grant GR068380AIA-HSR). Many
people have commented upon this paper or contributed
to the empirical studies that have informed it. We thank
especially, John Bond, Marie Campbell, Martin Eccles,
Catherine Exley, Ruth Graham, Eileen Kaner, Frances
Mair, Chris May, Maggie Mort, James Mason, Made-
leine Murtagh, Mary Ellen Purkis, Anne Rogers and
Richard Thomson.
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