22 Alienation

Marx believed that what made humans unique was our capacity to shape the world to our advantage. He argued that our best work made the world better. Birds can build nests, but only humans can design hospitals and public healthcare systems. Human work was anything but haphazard and, like Durkheim, Marx believed it was organised around social relationships (which is why we can talk about Marx as a sociologist). Hannah Arendt picked up on this in her book The human condition ^[1], arguing that human activity could be divided into labour, work, and action. Where labour addressed only life’s necessities (eating, toileting, reproducing, etc.), and work crafted the liveable world (building roads, writing novels, designing websites), action gave meaning to our lives. Where labour was predictable and mundane, and work was often skilled but repetitive, action was a spontaneous, inter-subjective activity, involving people speaking out to make the world better.

But Marx was also interested in the ways the benefits of social progress had been unequally distributed, and his iconoclastic analysis of life in 19th century Europe showed how this had been made possible. Marx argued that the Industrial Revolution had created an abundance of materials that people could use to their advantage: food, new technologies and scientific discoveries, raw materials for building, and new methods of transport blossomed in Europe after the 17th century. But the dividend of this surplus was not shared equally. In fact, European societies became significantly more unequal after the Industrial Revolution, as some people exploited the new collective wealth for individual purpose. The key, for Marx, lay with the ability to control the ‘relations of production’.

Marx drew a distinction between those people who controlled the mills and mines (the bourgeoisie), and those who worked in them (the proletariat). Controlling this relation of production determined who owned the means of production (the factory, the machines, the worker’s time and effort). Workers gave their labour to turn raw materials into goods and services, but the difference between what something cost to produce, and what it sold for, created a surplus that could be taken as profit by those who controlled the means of production. Thus, it was always in the interests of capitalism to keep wages low to maximise profits. But this was also the source of anger for workers, who saw the profits of their labour going to people who had not worked for it; ‘This surplus value costs the capitalist nothing, and is a tangible symbol of the exploitation of wage-earners’ labour power by employers’ ^[2]. Marx’s revolutionary idea was that the whole basis of Western society had been built on this rift between the bosses and the workers. He saw the whole political system, with its laws and regulations, customs and structures, as underpinned by this fundamentally exploitative economic ideology.

Marx and Engels believed this had a profoundly alienating effect on people. Being forced to leave homes and communities to find work, and competing with others to produce goods and services that people had no affinity with, was, for Marx and Engels, the source of profound spiritual, mental, and physical ill health. Alienation expressed the estrangement and detachment that accompanies peoples’ sense of the loss for the deeper meaning of our work. We should be working for our communities, helping those closest to us, not stitching footballs in a factory hundreds of miles from home, or filing in forms to ask an insurer to fund a few more treatment sessions. People’s work had been turned into a commodity, whose surplus value went not back to them, but to others whose interests depended on continually demeaning the value of their ‘species being’ (ibid).

Both Marx and Durkheim believed that people who lived and worked in their communities felt that their labour contributed directly to their wellbeing and the wellbeing of the people close to them. When people had to work on production lines, mines, prisons and hospitals, and labour for large, remote, multinational corporations, courier firms, and off-shore call centres, they are removed from their communities and lose a sense that their work really matters. Their work becomes a tradable, expendable, replaceable commodity over which they have no direct control. It becomes alien to the person’s humanity and is inherently dehumanising ^[3].

Michael Thompson suggests that ‘alienation can be understood as a particular kind of atrophy of moral concepts and moral thinking that affect the ways individuals cognize and legitimate the social world and their place within it’ ^[4]. Alienation is, at its heart, disempowering and dehumanising, or as David Foster Wallace suggested “the idea of giving yourself away entirely to the idea of working in order to achieve some sort of brass ring that usually involves people feeling some way about you — I mean, people wonder why we walk around feeling alienated and lonely and stressed out” ^[5].

Work, for Marx, was a ‘sensuous and embodied practice through which human beings transform[ed] the world around them, in accordance with plans, projects and aesthetic sentiments’ ^[6], and it reflects ‘our humanity and individuality back to us’ (ibid, p.5). And ’to live in accordance with our species-being is to live collectively, mutually recognizing one another as specifically human beings and thereby being able to recognize ourselves in this way’ (ibid, p.6). But Marx believed capitalism had ‘perverted the nature of work and prevented people from gaining fulfilment from it’ ^[7].

Alienation clearly has important implications for physiotherapists, partly because physiotherapy exists to help manage the ill health that accompanies the alienation of human labour under capitalism. But also because we are, ourselves, workers. Physiotherapists, like all health workers, know the importance of demonstrating enthusiasm, commitment, and reflexive professionalism for their work, and they know to mask their ‘true anxieties and hostilities’ ^[8]. But physiotherapists willingly contribute to their own alienation, by holding on to a professional identity that depends on practitioners’ ability to distance their work from the physical therapies that have been practiced for centuries in communities all over the world. The ability of physiotherapists to claim a right to work depends on alienating themselves from communities and individual lay people. And physiotherapists are also complicit with the other western, orthodox, biomedical professions in the process of reification; the Marxian term for the way the real harms of alienation are masked behind abstractions or ‘phantom objectivity’ ^[9]. (Reification occurs when people stop seeing human beings as the cause of hurt and harm, racism and sexism, for instance, and see ‘racism’ and ‘sexism’ as things in themselves. In a similar way, Marxists argue that when people’s genuine healthcare needs are reframed as demand for standardised care packages; when basic human needs are reconcieved as personal choices; or when services are reconstituted as commodities, the original force and effect of the person’s needs are conveniently lost.^[10].)

When physiotherapists emphasise outcome measures, objectify people as commodities, and attempt to provide universalised, evidence-based rationales for their care; when we claim our work reduces waiting times, increases choice and control, improves standards, and is more person-centred; when we increasingly talk of customers, consumers, personal care plans, personal health budgets, and health system evaluations; and when we talk of empowering consumers with greater choice, but limit that choice to a ‘predetermined menu of services’ ^[11], we are acting every day to revivify the alienation that lies at the heart of capitalism ^[12][13].