64 Being responsible

One of the most surprising, and yet powerful, features of healthcare in late capitalism, is the speed with which people have taken up the rhetoric of personal responsibility. Personal responsibility is underpinned by the belief that illness represents ‘culpability in the face of known risk’ ^[1]. Given how much health information is now available to us, we have no excuse but to be healthy. And if we do become ill, we only have ourselves to blame. Ergo, when a person becomes ill, it is their responsibility, and so they should pay for their treatment and care. The genius of this rhetoric is that it effectively reduces the state’s responsibility for healthcare — a central plank of neoliberal reform — without appearing to be punitive, whilst also opening healthcare up to greater choice and a massive marketplace for newly privatised services. ‘There is no doubt’, Bill Hughes argues, ‘that this apparent democratisation of the relationship between professional and patient suited Western governments intent on reducing public expenditure and squeezing the welfare state’ ^[2][3].

But the corollary of personal responsibility is that ’individuals themselves should be “supported” only in their quest to cease needing support’ ^[4], leaving us all with the sense that we are now vulnerable to our own fates (ibid). In their efforts to mine one of the last vast untapped markets for capital resources, Western governments — ‘intent on reducing public expenditure and squeezing the welfare state’ ^[5] — have fundamentally changed the relationship between the health professional and the public.

‘In the post-professional age the state — no longer the ‘nanny’ of old — expects its ‘active citizens’ to take responsibility for their own bodies. The layperson has been transformed into the rational consumer and medicine has been subjected to political, social, cultural and economic forces that have driven it further into the logic of commercialism’ (ibid).

Isabelle Stengers ^[6] has argued that health service ‘consumers’ should now be seen as ’intelligent ‘connoisseurs’ of complex, highly refined, social bodily practices and the scientific knowledges associated with them’ ^[7]. Connoisseurs have the advantage of both first-hand experience, and access to knowledge and information available to all. Similarly, the idea of ‘active patienthood’ is now widely acknowledged as a normative good ^[8], with the expectation that ‘patients should inform themselves, claim their expertise, and participate in their care’ ^[9].

The rhetoric of late capitalism assumes, of course, that everyone has equal access to the resources that have emerged from the deconstruction of earlier social structures. What is also clear is that a significant divide now exists between those who can take advantage of new cultural, economic, political, and social freedoms, and those who cannot ^[10]. And the increasingly wide social gradient between the richest and poorest in society that neoliberalism and globalisation perpetuate ^[11][12], are deepening the divide between the traditional centres of power and affluence and everyone else. (For an example of this in the context of rugby-related spinal cord injury in South Africa, see ^[13].)