The French philosopher Michel Foucault warned that public health threatens the principles of liberal democracy. Our political system, he argued, depends on us imagining each other as citizens working out collective rules to protect our rights. Our conception of public health, however, results in us thinking of each other as victims and vectors of contagion. Appeals to “science” and “health” suspend our rights and the deliberative reason of the democratic process. But science and health are not neutral, objective categories. They always contain, and usually conceal, projects for reshaping humanity.
Foucault insisted that the totalitarian regimes of the 20th century had used public health concerns as covers to pursue their tyrannical ends. The Nazi regime committed genocide and mass euthanasia in the name of racial hygiene, and the Soviets imprisoned dissenters in psychiatric asylums. Before this year, Foucault’s argument might have appeared hyperbolic. But today, as cities and states debate whether to continue coronavirus lockdowns or declare racism a public health crisis, it should find a hearing.
In one of his first books, Birth of the Clinic (1963), Foucault argued that liberal democracy has always been at odds with public health. In the first phases of the French Revolution, for instance, radical liberals attacked the public health network of the French monarchy as anti-democratic: Hospitals confined the sick, and medical schools confined knowledge and the right to practice medicine away from ordinary people. During the wars of the French Revolution, however, the army’s need for doctors forced the revolutionary government to restore a centralized medical bureaucracy, linking hospitals and universities to the state in a common project of surveillance and control. Public health would have to be an exception to liberal principles.
Foucault eventually broadened his critique, arguing that all the “sciences of man” — psychology, sociology, pedagogy, etc. — require exceptions to liberal democracy. In his 1976 lecture series, “Society Must be Defended,” he warned that experts in these fields are increasingly empowered not only to suspend our freedom in temporary crises but also to act as a “disciplinary power” in our daily lives, reshaping our behavior and even our identity. Schools, workplaces, and (we could add today) social media are all “fields” in which power is wielded in small but cumulative acts of “domination” that often escape our notice. Consider, for example, how Twitter reshapes how we form our opinions, subtly pressuring us to render our views more likable and shareable. Supposedly democratic platforms exert power over us far beyond what their formal rules would suggest, reaching deep into who we are.
Western political movements since the French Revolution, Foucault claimed, have not understood how to resist this form of domination. They have aimed at enacting laws, asserting rights, and seizing “sovereignty” — the power that is imagined to reside in the heart of the state. Our rights, however, are not being suspended by a master at the center of politics whom we could overthrow or bind with legal codes. Rather, they are menaced from a thousand directions at once. This menace is permanent and ubiquitous; no sovereign stands behind it. This is not to say that power is some mysterious essence but simply that it accumulates from many small actions rather than radiating from a central point. No deliberate project of patriarchy is responsible for men’s historical domination of women. There is no plutocratic conspiracy behind income inequality.
After flirting with various forms of radicalism during the 1970s, Foucault came to believe by the early 1980s that what liberal democracy needed was a return to its 18th-century roots. In 1983, a year before his death, he gave an interview on “Social Security,” a term that in French refers to the system of healthcare rather than old-age pensions. He noted that we are confronted with a dilemma. Excluding people from public health means exposing them to danger. But public health is itself dangerous, threatening to reduce our “autonomy” for the sake of someone else’s notion of our well-being.
Talk of rights is not much use here. Medical experts and politicians acting on their advice dismiss rights, while demands for a “right to health” fall into incoherence. Health is a state of affairs that requires a unique combination of inputs in each case. It is difficult to imagine how the abstract, universal language of rights could help orient our thinking on the intertwined problems of how to distribute scarce medical resources and how to balance individual freedoms with the irreducibly authoritarian dimensions of health policy.
Thinking about these conflicts in terms of rights, Foucault said, distracts us from paying attention to the way public health decisions are taken. Every day, “choices are being made” about where to direct resources, what levels of risk are acceptable for what populations, who lives, and who dies. But these decisions, whether made by government officials or agents of insurance companies and hospitals, usually “remain silent.” Often, we do not even know the criteria according to which they are made.
This in part is our own fault. We accept the domination of experts who abrogate our liberties because we are terrified of assuming responsibility for “life and death.” To even discuss such matters (to observe, for example, that medical resources are limited and that in some cases, people must be denied treatment) provokes “a general outcry.” Here, Foucault observed, “rationality becomes a scandal. … But I think it is pointless to avert one’s gaze.” Life-and-death decisions are being made and ought to be made in public, in accordance with rationally articulated values.
The American Right has long resisted such conversations. It has appealed to the idea of patients as consumers in a marketplace of healthcare with a “right” to choose their own doctors and treatments. Hiding behind this language of rights, conservatives have shirked the responsibility of making decisions about public health. So too have they avoided defining health. But Foucault insists that behind every project of public health are norms of how people ought to be — otherwise, one could not tell the healthy from the sick. Perhaps this absence of a conservative ideal of health has allowed the Left to appropriate health to its own ends. When the Left declares racism a matter of public health, it invokes notions of well-being, trauma, pain, and safety to frame dissent from its political agenda as an attack on science, medicine, and morality.
The tension between liberal democracy and public health, Foucault suggests, is not going to disappear. If we cannot eliminate the illiberal dimensions of public health, we can at least try to reveal the criteria according to which public health decisions are made — and to reshape these criteria through democratic and rational debate in line with a substantive vision of healthy individuals in a healthy society. If not, these decisions will be made by others in conformity with their own vision of “health.”
Blake Smith is a Harper Schmidt fellow at the University of Chicago, where he works on cultural ties between France and India.
