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When health means illness

Analysing mental health discourses and practices in Ireland

Derek Chambers

In this chapter, the author utilizes ideas drawn from governmentality to explore the emergence, and sometimes uneasy co-existence, of the biomedical discourses in the mental health policy arena. As Michel Foucault and other authors have noted, discourses constructing mental health have been strongly tied to biomedical understandings of mental illness and the medical speciality of psychiatry. The operational elements of A Vision for Change: Report of the Expert Group on Mental Health Policy (AVFC) betray the claims to whole-population relevance of mental health and reinforce a narrow conception of mental health as a euphemism for mental illness. The theoretical framework of governmentality can be helpful in exploring tensions between the mentalities and practices of governing, and discourses as they have developed around mental health policy and practice in Ireland.

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Edited by: Claire Edwards and Eluska Fernández

Recent years have witnessed a burgeoning international literature which seeks to analyse the construction of health and health policy through an analytical lens drawn from post-Foucauldian ideas of governmentality. This book is the first to apply the theoretical lens of post-Foucauldian governmentality to an analysis of health problems, practices, and policy in Ireland. Drawing on empirical examples related to childhood, obesity, mental health, smoking, ageing and others, it explores how specific health issues have been constructed as problematic and in need of intervention in the Irish State. The book focuses specifically on how Jean Jacques Rousseau's critical social theory and normative political theory meet as a conception of childhood. The 'biosocial' apparatus has recently been reconfigured through a policy framework called Healthy Ireland, the purpose of which is to 'reduce health inequalities' by 'empowering people and communities'. Child fatness continues to be framed as a pervasive and urgent issue in Irish society. In a novel departure in Irish public health promotion, the Stop the Spread (STS) campaign, free measuring tapes were distributed throughout Ireland to encourage people to measure their waists. A number of key characteristics of neoliberal governmentality, including the shift towards a market-based model of health; the distribution of power across a range of agents and agencies; and the increasing individualisation of health are discussed. One of the defining features of the Irish health system is the Universal Health Insurance and the Disability Act 2005.

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Joanne Wilson and Lindsay Prior

The Irish government has developed policies that set out its vision, priorities and direction for improving and sustaining the health of its people. This chapter critically appraises how these strategies have been configured to structure responsibility for health. It exposes a number of key characteristics of neoliberal governmentality, including the shift towards a market-based model of health, and the distribution of power across a range of agents and agencies of health. The need to reduce healthcare expenditure appeared in the first national, strategic public health policy, Shaping a Healthier Future. The chapter illustrates three evolving rationalities in strategic public health policies in Ireland. They are a market-based model of healthcare, devolution of responsibility, and capabilities and techniques to manage the self and ensure individual behaviour aligns with political objectives.

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Ciara O’Dwyer

This chapter seeks to analyse the reform process initiated in 2005, examining the policy tools used to improve care provision and their impact on older people. It examines the impact of recent budgetary constraints on the long-term care sector, as a result of the recession in Ireland's free market economy. The chapter also examines how older people are conceptualised and analyses the relationships between the state and other stakeholders in the design and implementation of long-term care reform policies between 2005 and 2015. It is guided by a governmentality perspective, critically analysing the changing power relations within the long-term care sector in Ireland. Drawing on the particular conceptualisation of power, Michel Foucault developed the concept of governmentality, or 'the art of government'. Foucault's work on governmentality has been used by many other scholars as a framework for analysing power relations in society.

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Governing the future

Children’s health and biosocial power

Kevin Ryan

This chapter examines the writings of Jean Jacques Rousseau. It focuses on how his critical social theory and his normative political theory meet as a conception of childhood that would come into sharper focus during the nineteenth century. The chapter also examines reformatory education and public hygiene, focusing on how the public health strategies were developed and deployed in Ireland. Both in terms of design and strategic objective, the penal reformatory school exemplified biosocial power in that it was deployed as a social technology to refashion life that had been deformed by social circumstances. The chapter looks at how the 'biosocial' apparatus has recently been reconfigured through a policy framework called Healthy Ireland, the purpose of which is to 'reduce health inequalities' by 'empowering people and communities'. It also looks at how the prescriptive thrust of Emile was made practical through a pedagogical form of philanthropy.

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Governing organ donation

The dead body, the individual and the limits of medicine

Órla O’Donovan

This chapter explores how the efforts to increase the availability of human organs by moving to an institutional arrangement based on presumed consent necessarily extend beyond shaping people's cultural attitude towards organ donation. Transforming the prevailing cultural attitude and habitual behaviour in respect of organ donation also requires subtle but significant shifts in how people imagine the dead body, the individual and her or his responsibilities to others, and the limits of medicine. The chapter considers the debates in light of the ideas of Michel Foucault about the construction and government of the modern individual. Central to Foucault's conceptualisation of governmentality is that the modern sovereign state and the modern autonomous individual, homo economicus, co-determined each other's emergence. Peter Wehling is ambivalent about the emergence of active biological citizenship, which he regards as a new and significant element in contemporary governmental regimes of medicine.

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Governing healthcare

The case of Universal Health Insurance – by competition

Cliona Loughnane

This chapter discusses how the trajectory of health policy in Ireland enabled the imagining of Universal Health Insurance by Competition (UHI-C). UHI-C represents both an emerging discourse for governing healthcare and a governmental technology-in-development. It also represents a particular moment in Irish health policymaking. The chapter argues that UHI-C was a rationality and technology of advanced liberal governing, masquerading in claims to social solidarity. Without UHI-C implemented in practice, the chapter uses existing policy documents to critique the proposal as an example of the rationality and technology of advanced liberal government developed by Nikolas Rose and Peter Miller. The chapter examines the UHI-C documents in terms of four elements of governing in an advanced liberal state. The four elements include seeking to govern at a distance; placing responsibility on individuals through choice; the management of risk; and the fragmentation of the social sphere into multiple communities.

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Doing the ‘right thing’?

Children, families and fatness in Ireland

Michelle Share and Perry Share

This chapter analyses recent Irish interventions into the 'obesity' discourse from the critical stance. It focuses on evidence from the first longitudinal study of children in Ireland, Growing Up in Ireland (GUI), and how its findings have entered the media and policy arenas. The analysis is based on secondary documentation, including published reviews of childhood obesity prevalence and GUI reports. Families and children were to be responsibilised to protect against the risks of overweight and obesity through educational and lifestyle interventions. The chapter considers some examples of how child fatness nevertheless continues to be framed as a pervasive and urgent issue in Irish society. The framing of childhood obesity illustrates how 'governmentality works by positioning or representing a problem in particular ways'. Body Mass Index (BMI) is even less satisfactory as a measure of childhood 'obesity'.

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The contemporary self in tobacco control

Exploring the introduction of the smoking ban in Ireland

Eluska Fernández

This chapter focuses on one of the most well-known episodes in the history of tobacco control in Ireland: the introduction of an overall workplace smoking ban in 2004. It draws some key ideas and concepts put forward by governmentality studies. The introduction of the smoking ban in Ireland is considered by politicians, public health and anti-smoking advocates and Irish citizens as one of the biggest success stories in the history of public health policy and tobacco control. The chapter discusses some of the social and political implications of conducting a governmental analysis by drawing attention to the fact that the regulation of smoking became interlinked with social and moral processes. It exposes how some of these processes played a symbolic role in promoting boundaries between different social groups.

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Governmentality, health policy and the place of critical politics

Eluska Fernández and Claire Edwards

This conclusion presents some closing thoughts on the concepts discussed in the preceding chapters of this book. The book explores the potential of governmentality-inspired ideas to develop a more nuanced and indeed critical understanding of the construction of health-based policy in Ireland. One of the key points underpinning accusations of governmentality's limited critical potential relates to the suggestion that studies often fail to capture the messy actualities of social and political relations. The book provides a clear example of how different and often competing voices, each drawing on different types of knowledge, build into governmental visions and approaches to organ donation. It illustrates how the management of obesity is increasingly being placed in the hands of individuals, by vesting them with a technology designed to monitor their waist circumference.