A socialism of the professional ruling class? A personal note on "communicative capitalism," democracy, medicine, and the state
Sometimes I think this is my own biggest problem with American society today. I recognize that there are worse things that can happen to a person. But it's this: professionals employed in any way with any authority over other people who seem to come under that authority are often very difficult to talk with if you approach the conversation as I always do, in the "petty bourgeois" manner of assuming that it is both legitimate and possible to both want something and try to get it through the discussion.
Example: I suffer from pruritis, a generalized itch of perhaps uncertain causation. I saw a doctor on Friday who diagnosed it as allergy because she saw red spots on my arms from itching. She told me see a general practice doctor who can refer me to an allergist, to find out what I am allergic to. And she prescribed a drug, which is actually classed as a steroid, prednisone, for the itch. All this makes perfect sense to me and sounds hopeful. The doctor I saw sees people only on an urgent care basis, and she is actually a Nurse Practitioner, who, like most in her profession, are actually much more engaging and helpful than most M.D.s. I of course thanked her.
(I wonder if I am in the territory of Italian filmmaker Nanni Moretti's wonderfully ironic 1994 comedy, "Caro Diario" (Dear Diary), now available for streaming at Film at Lincoln Center. He gets a mysterious condition, sees all kinds of doctors who are experts on it, none of them solves the problem, and, at the end of the day…..)
Yesterday I took the first of five tablets; I was to take one every day. It turned out I had unusual trouble falling asleep last night, a problem I have often had, but I had to wonder if the steroid medication made this worse. I checked on line, and indeed, sleeplessness is a common side effect. So I call the health clinic I went to on Friday. The doctor I saw is off today, it’s Sunday, but another doctor was there. I was connected. I explain it all.
The question is obviously whether I should continue to take the steroid meds as prescribed and do nothing else and just hope that I get enough sleep. Or take something else to help me sleep. Or modify the dosage.
I cannot get this problem solved without being able to participate in the discussion and raise the concerns that I have. Nor can I do so unless the final decision of what to do is mine. Many doctors don’t like that. Psychiatrists can do you a great deal of harm if you try. She is an NP at an urgent care clinic. My difficulty is the task of explaining my problem fully and having my need as I define it taken into account. Why is that? Because of this, which is the sticking point:
My interest is not just in serving rightly the God of medicine, who normally expects people to do as the doctor instructed, since she or her serves that God knowledgeably. What is my problem ?
It’s simple: I want the itch to be controlled or limited, and I also want to sleep. The problem is getting her to understand that the most important concern here might be something I decide, since there is a decision required here: my need to sleep which is determined by the demands of my work and life, must for me be balanced against the need to control the itch. This colleague doctor eventually said, well, then you can take half of the (scored) tablets and see if that works better. I was hoping she would say that, and I called in fact because I want a medically knowledgable person who knows at least the basic facts of my case to participate in this decision, because I don’t know what the effects might be apart from making it easier to sleep of taking half the dosage. I want her to not give me orders, but advise me.
But our medical culture is not democratic but is modeled on the same military principles of command and hierarchy that our corporate and government culture are modeled on.
She first replied by telling me that the sleeplessness is temporary and will go away when the five-day medication regime is over. That is: your body will not be harmed by not sleeping for five days. Yes, I know that, but my question is not about that, but about what is the best way to both limit the itch and get sleep in the next five days. I want to sleep. Maybe that’s just my problem and not a medical one. I may have to make sure to frame it as a medical problem and not, say, a personal financial one, though it is also that. I need to be able to get work done, and it’s very hard to do that on inadequate sleep. I want to itch less if possible, but my first priority is sleep.
She was very resistant, understandably, to making any changes to what I am directed to do. She first said I could drink chamomile tea to help in getting to sleep. I told her that in times past I often tried such herbal and other remedies, and they did not work. Now I take a medication which does help me sleep, but the steroid medication seems to counteract that effect somehow. She’s not in the right specialty perhaps to rule on those meds (and whether I should increase them).
She is very insistent and it is very difficult to get her to recognize my concern and so understand my question at all. I find this to be normally the case with American professionals and managers and others employed in any way that involves managing people.
I say this partly hoping some persons with medical or nursing backgrounds may have some thought on this matter, which if expressed I would treat as not authoritative “medical advice” but only the suggestion of a possible question to pose. The conclusion of the discussion was happy with one caveat. She said I could take half a pill (again, the pills are scored to facilitate this). My follow-up question then was “so then I take one half pill for 10 days instead of 5?” No. Of course not. She does not want to entertain the possibility of actually modifying the original prescription. I think this is the heart of the matter.
The medical question would obviously be whether I should take it for 5 days or 10. Since the original doctor at the facility (she calls herself doctor, and I have established that an NP is indeed just as good usually for my purposes) will be back on Monday, I will plan to either call her tomorrow or on the 5th day, and ask if I should take half pills for five more days or stop.
This has been my greatest cause of personal tragedy in my life: all I have ever needed was just the opportunity when faced with anyone in authority to be able to say and ask for what I want, and do so in what philosophy sometimes calls “the space of reasons.” Of course, it’s partly a class issue. The poorer and less officially educated you are in America, or the less titled your profession entitlingly is, the more you are expected to obey authorities of every kind without asking any questions. The richer and more ‘privileged’ you are in this respect, the more likely you can.
In fact, I am in the market also for a psychiatrist, for medication consultation only (I deny that medicine has moral authority over souls or persons in quite the way it seems to demand), who will respect me enough to take seriously what I want and why, and not just be sheepishly compliant, or threaten punishments if I am not. I believe that this means first of all finding a doctor in private practice (who takes insurance) in a relatively white and wealthy part of town.
It also makes me politically something of a Habermasian. What is wrong with this is what limits it. This is the way in which the old left ideal of democratic autonomy and self-determination has found its realization not upward but downward, so to speak, in “communicative” capitalism.
I was shown this once in a wrongful psychiatric hospitalization. They actually brought in a man whose job was to say provocative things to people like me. He told me “I learned here that everything is about me,” and that “I never ‘communicated’ until I was in mid-life.” Managers in a professionalocracy expect those they manage and so have authority over to communicate what they want and need so it can be used to help them, and in the ways, and with the limits, that existing social institutions and hegemonic practices and discourses allow. This “communication” precisely can situate persons outside society and then as lacking in its own very rules and principles and conditions of possibility. In a correctional institution, which used to be a name for prisons but actually really today is medical and therapeutic institutions and practices (such as the therapeutic support or 12-step group, and various “spiritualities”), people are given to understand that, in an almost colonialist sense (and it partly comes from that, and the American version of it, which included slavery), they are “outside society” and really beneath it, literally Untermenschen or under- person, persons under management, or (re)formation, or therapy (or salvation: hence the importance of religion in America in management of the poor), persons under treatments that ai or pretend to prepare them (like schoolkids) for entry or re-entry into “society,” the very idea of which has always been one of inclusion through and with exclusion). If “everything (here) is about me,” than “I” am referred to idiocy, the condition of the person who can only speak about himself. Managed idiocy is the situation of the therapeutic patient, who can only speak about his own problems, or the psychiatric one, who can only be understand as speaking about his illness. It’s not unlike confession, as Foucault understood.
If I became a successful man of reason who has found a, for him, good enough way of being able in institutional and social contexts in America to ask for and even try to insist on getting what he wants, then I would be philosophically a Habermasian, and since that position is Kantian and perhaps Hegelian in a certain way (the “positive” way that is that of Brandom, not the “negative” way of Zizek), the critique of it is Marx’s critique of bourgeois ideology and society and of Hegel. Predictable, my success will be tied to the same class conditions of understanding of self and society and Being and world that make it possible sometimes for me to be treated as competent member of the professional class.
This is one idea of socialism. It is Habermas’s and, why not, Brandom’s; it is one that American philosophers could understand; it is not Marx’s and it is not Foucault’s. Foucault’s critique of discourses and social power may be even more fundamental. It omits the possible redemptive character of a socialism styling itself as the liberation and then rule of the working class. Such societies have existed and they can and did sometimes have real advantages. To wit, they can be more democratic, although historically they were not, at least not as states rather than just parties. The Soviet Union had a better class structure than the United States and certainly England, which has a non-republican structuration of class that renders English society conservatively aristocratic and fatalistic. France and most of Europe today are actually kind of in between. The French state has aspects of socialism. In France and the Soviet Union, the ruling class is or was the professional class, and its power is bureaucratic. This empowers intellectuals and in a certain way. The two classes of late modern society are the non-university-educated working class and the university-educated professional class. The Soviet Union theorized these as ultimately the same class, which both is true and isn’t. Kantian, Hegelian, and Habermasian ideologies of communication and discursive universality (Hegel: everything can be theorized, and all social conflict resolved on the plane of theory when it takes forms of itself, or of “reason,” as its objects, as it does when it reaches the level Hegel calls “Geist” (mind or ‘spirit,’ in the intellectual European sense and not the mystified sense of American “spirituality”)).
You could build socialism this way. It would not be communism, but the standard line that socialism is a stage on the way to communism is not in itself necessarily without credibility. Such a socialism, though, would look to many people like a self-transformation of capitalism with its class domination —
—rather than: something more than something more radical, which just might be once again something that can be and is placed on the historical agenda, with all its stakes, risks, uncertainties, opportunities, and possibilities —-