Health Care Reform Debate and Feminine Sexuation: Passage to the Act

(Dear reader, sorry for the delay in posting--this summer has been one long emotional roller coaster ride so far.)

Part 3 of “Health Care and the Community Economy: Towards an Ethics of Surplus and Geography of Sufficiency.”

Feminine Sexuation and Health Care Reform

So far we have learned what it is like to fail in relation to economic imperative—to fail to balance social reproduction and economic growth … My qualitative research alerted me that it is also possible to fail in relation to one’s ethical commitments.


One interview that stands out in this regard was with Dr. Norman Haug of Del Norte Colorado—driving force behind the creation of The Rio Grande Hospital. Del Norte is a remote town in South East Colorado with a mostly poor rural farming population and a seasonal tourism industry. Like a lot of poor rural communities access to health care was a real problem. Norman was able convince HUD to provide Del Norte with a loan type 242 that allowed for the construction of a critical care hospital to serve the local community. To obtain the grant he had to prove to HUD that the hospital was economically viable.

First Norman needed to raise a 1.5 million dollars in order to qualify for the loan—the first of its kind to be provided by HUD outside of the NY/NJ area. In addition to solicitations large and small the land for the hospital—valued at 400K--was also gifted by a land owner. To prove that the critical care hospital was viable one argument Norman made was that it would serve the tourists that came to the area for hunting and other excursions. The decisive point proved to be the hospitals designation as a critical care facility by Medicare.

This meant that Medicare—the insurance form for 70% of the patients—would reimburse the Rio Grande on a cost basis rather than according to capitated formularies—in the absence of this arrangement, the hospital would lose money. One of the rationales behind the critical care hospitals is that they provide care in sparsely populated areas that would otherwise fail to constitute a viable market.


This leads some to dismiss the Rio Grande as a state charity case but Norman disagrees on two counts: First, We would not argue for the centralization of police or educational services on the basis of market demand… nor should we argue for a centralization of medical services. Second, once transport and higher overhead in urban hospitals are figured into the equation—critical care facilities and rural hospitals are cost effective responses to definite need.

Situating the Rio Grande in the Diverse Economy

It is useful to situate the story of the Rio Grande hospital in the context of the diverse and community economy diagram, with its partial typology of economic difference in the dimensions of exchange, compensation and organization. For those of you familiar with A Post-Capitalist Politics, it will be unnecessary to go over the way in which this representation of the economy as a space of open-ended heterogeneity describes an actually existing diversity of forms of exchange, compensation, and economic organization (the dimension of class). The Rio-Grande is a state capitalist enterprise that exists to serve a particular constituency. While it has clearly been enabled by a generous state transfer from HUD and its designation as a critical care facility by Medicare, it’s also clear that it exists as a community asset because of the generosity of local citizens. In turn, it is a context in which Norman and the other physicians are able to generously serve the care needs of the local and transient population—including legal and illegal immigrants. (45% of care is free care) and the market of insured patients.

Thus the Rio Grande is “viable” because of the support that it receives and because its mandated purpose is to service a geographically finite need. There is, of course, a limit to Rio Grande’s capacity but it no longer needs to be read in relation to infinite demand and self-interested practitioners.

Lacan’s counter-posed feminine logic becomes relevant here. In this view there is no constitutive exception—all are subject to the law, and yet no one is completely subjected. In the world of feminine sexuated logic limits remain, including limits to care, but they are seen as provisional. Here “scarcity,” and the need for “economic growth,” no longer act as over-arching imperative. In my view, it is this move towards the relational possibilities (and constraints) of a feminine logic rather than the fixed miserly injunction of masculine logic that allows us to re-imagine the politics of health care reform in relation to sufficiency.

Feminine logic, as Copjec says, “obliges us to recognize the finitude of all phenomena, the fact that they are inescapably subject to the conditions of time and space and must therefore be encountered one by one, indefinitely, without the possibility of reaching an end, a point where all phenomena would be known. The status of the world is not infinite but indeterminate.”

Health care reform will continue to fail us, but we will fail to arrange and allocate care in relation to an ethical imperative rather than a miserly economistic imperative. We need a language of partial subjection in order to produce a politics of ethical possibility. A sufficient response to definite need is something that is intelligible in the spatio-temporality of needs encountered “one at a time.” Likewise, the range of existing assets, and the generosity of the community—and here I include the state as simply a part of community—needs to be encountered in their particularity also. While this indeterminate mobilization of social surplus, generosity and ethical commitment is what allows for the Rio Grande to succeed—the success of community health centers elsewhere would depend on the identification of definite resources (and constraints) that occur in any given area.

Fifty years ago people took the risk and they built these hospitals, we need to do it again. And we just need to get it done… Get the hospital built and let the person whose going to be here ten years from now worry about it. I mean that sounds callous but that’s what it amounts to. (Norman 2005)

Derrida taught us that an act can only be considered ethical when the outcome of the act is uncertain. What is clear from his statement here is that Norman truly is not clear what the outcome of his efforts will be but he is willing to act anyways. Perhaps Norman’s status as an ethical agent—his willingness to take the risk in order to “get it done”—allows us to see the typical mainstream approach to health care reform, as mired in a masculine sexuated logic of impossibility, as an imaginary solution whose elegance and inevitable failure leaves things exactly as they are. The imagined social harmony between the conservation of capital and the equitable allocation of care is never arrived at and this failure is symptomatic of a castrating approach to health care reform.

In contrast, Norman’s capacity to meet the needs of the immediate community, his adoption of the standard of a sufficient response in relation to definite pressing needs, is sustained not by the idea of a final/fantastic end point but a spirit akin to what Zizek describes as “enthusiastic resignation.” Through Norman we can come to see the difference between the failure to embody (the reconciliation of equitable health care allocation and continued economic growth) versus a failure in relation one’s ethical principles (to care and accept whatever comes as a result of this commitment).

How is that Norman came across this affective disposition, this willingness to pass to the act?

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)