Health Care and the Community Economy: Towards an Ethics of Surplus and Geography of Sufficiency. (Part 1)

Introduction

In a recent presentation entitled “Freud in the Field: Some Early Twentieth Century Encounters in Participant Observation,” critical geographer Laura Cameron argued that Bronisław Kasper Malinowski’s participant observation was inspired by Freudian psychoanalysis—the productive tension it creates between engagement and reflection. Though Malinowski later repudiated psychoanalysis as a result of a controversy over the universality of the Oedipus complex it was clear that he continued to have a great personal respect for Freud.

My own encounter with the subjects of my field research was less directed by a conscious commitment to participation, observation followed by reflection (self-analysis) than it was about the way in which people I interviewed in the health care field crystallized my comprehension of the psychoanalytic theory I was exposed to in the course of our seminars from 1999 through 2004. A principal theme that emerged from my qualitative research was that care providers, from physicians to informal caregivers, shared a common experience in the labors of care:

• A drive to care that we can recognize as ethical in the Lacanian sense—a non-pathological act that remakes the subject. (The key text here is Alenka Zupancic's indispensible Ethics of the Real: Kant and Lacan (Verso, 2000).)
  
• How attending to this act of care both involves self-transformation—and an attenuation of the boundaries between self and other in encountering the patient, a process that can threaten psychic and physical exhaustion or financial ruin in the case of informal care givers.
• This common ethical drive suggests the need to reconceptualize the process of health care reform as one that focuses on the centrality of this ethical drive in a way that allows caregivers to be transformed rather than undone by their efforts.

In the process of reflecting upon the themes that emerged from my research convinced me that the Lacanian distinction between the Analytical and the University discourse enables me to differentiate health care reform as a process that pays attention to an ethics of care from the bureaucratic process of “cutting.” From the perspective of the four discourses, late Elizabeth Wright, in her Psychoanalytic Criticism (Routledge, 1999) argues that the function of language is not communication but the creation of a common bond between subjects. The adhesive power of this linguistic bond is to be found in the dis-connection between the unconscious of the agent and the addressee and not in the transmission of knowledge.

Four Discourses

It is beyond the scope of my writing here to restate once more the matheme permutations that arrange the master signifier (S1) (asserted entry point), knowledge (S2), the object-of-desire (a) and the split subject (S barré), in relation to conscious/unconscious of the agent and the conscious/unconscious of the addressee. Suffice it to say the University discourse, in its exposition of knowledge (in this case how to regulate the allocation of health care), presents itself as an objective knowledge. What is unconsciously produced in the recipients of this knowledge is ambivalent identification with what is pronounced: does this speak to my desires or thwart them? What remains inaccessible in this communication is the foundational assumption (the master signifier) which sets the rules of the knowledge production in the first place. It remains in accessible because it resides in the individual/institutional unconscious of University discourse. In contrast, the effect of the Analytic discourse possesses the potential to dislocate this foundational assumption as the unconscious knowledge of the analyst unfolds in the course of the analysis.

I cannot claim to have fully incorporated the four discourses into my work, methodologically or analytically, but I have been inspired by others to think about the implications of their political significance. It strikes me that Yannis Stavrakakis’s (see his upcoming The Lacanian Left) approach is to see in the Analytical discourse the basis for formalizing radical democratic politics. My dear friend Ken Byrne sees in the Analytic discourse a topographical space in which we view the object (in his case, the education reform) from a different perspective—having traversed the fantasy that emerges as a consequence of University discourse’s failure to fully capture the subject or to justify its unconscious assumptions and beyond the hysterical objection, we arrive at the possibility of a new organization of the problematic (a new master signifier).

In examining health care reform discourse—spilling out in a flood of academic and policy press—it became obvious to me that that an economy of scarcity was the master signifier that informed all efforts at health care reform. Further, the failure to domesticate or contain the effects of this scarcity produced an ambivalent subject whose protestations formed the basis for the further enunciation of the University discourse of health care reform—just as Lacan argued that hysteria constitutes the basis for the further advancement of knowledge (Lacan Seminar XVII). In listening to this “knowledge” in relation to health care reform, what emerge are both its repetitive quality as well as those moments where it is clear that we might look at things in a decidedly different way. It is here that a methodological approach to qualitative research can be usefully compared with the analytic process. There are moments in the course of research—both archival and in interview—where this alternative perspective emerges as a clear and coherent alternative. One such moment was in watching an interview the Bernard Leitaer recorded by Ted White and Karen Warner in the summer of 2006. While watching this interview I had a moment where someone else clarified perfectly what I had been attempting to formalize in the course of my research and writing. Bernard Leitaer allowed me to see an approach to health care reform that is located beyond an economy of scarcity as a foundational assumption.


Bernard Lietaer is one of the principal architects of the euro and a prominent player in international currency markets. He has recently become interested in alternative currency systems, especially mutual credit systems like the Akipu in Japan which allows for adult children to accumulate credits by caring for older adults near their home and then transfer these credits to their parents in need of care to be redeemed through someone else’s efforts in the system. One should take note that this is a system where the capacity to care expands as more people participate in the exchange network. It is a system of care that aims at a sufficient response to the growing problems of an aging population. Lietaer argues sufficiency, not abundance or excess, is the true opposite of scarcity. Rather than being its simple negation, it describes a different relation between necessity, limits and capacity. The limit remains but it is experienced differently—its status is indeterminate rather than given a-priori. Looking at health care reform from the perspective of an indeterminate limit—it is possible to see the Akipu system as a limited response to elder care whose potential sufficiency grows as more people participate in this alternative system of production and exchange. It might create the conditions for cooperative relations of production and ethical relations of exchange called for in the conclusion of Kojin Karatani’s Transcritique.

This is the relationship with the process of health care reform that we need, but I am getting ahead of myself.

(To be continued in Part II)