Technogovernance: Evidence, subjectivity, and the clinical encounter in primary care medicine

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Social Science & Medicine 62 (2006) 1022–1030

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Technogovernance: Evidence, subjectivity, and the clinicalencounter in primary care medicine

Carl May�, Tim Rapley, Tiago Moreira, Tracy Finch, Ben Heaven

Centre for Health Services Research, University of Newcastle upon Tyne, Newcastle upon Tyne, NE2 4AA, UK

Available online 12 September 2005

Abstract

Technological solutions to problems of knowledge and practice in health care are routinely advocated. This paper

explores the ways that new systems of practice are being deployed as intermediaries in interactions between clinicians

and their patients. Central to this analysis is the apparent conflict between two important ways of organizing ideas

about practice in primary care. First, a shift away from the medical objectification of the patient, towards patient-

centred clinical practice in which patients’ heterogeneous experiences and narratives of ill-health are qualitatively

engaged and enrolled in decisions about the management of illness trajectories. Second the mobilization of evidence

about large populations of experimental subjects revealed through an impetus towards evidence-based medicine, in

which quantitative knowledge is engaged and enrolled to guide the management of illness, and is mediated through

clinical guidelines. The tension between these two ways of organizing ideas about clinical practice is a strong one, but

both impulses are embodied in new ‘technological’ solutions to the management of heterogeneity in the clinical

encounter. Technological solutions themselves, we argue, embody and enact these tensions, but may also be opening up

a new array of practices—technogovernance—in which the heterogeneous narratives of the patient-centred encounter

can be resituated and guided.

r 2005 Elsevier Ltd. All rights reserved.

Keywords: Technogovernance; Primary care; Medical knowledge; United Kingdom

Introduction

Recent sociological accounts of technological change

in medicine—whether they review apparently global

developments in the domain of technoscience (Clarke,

Mamo, Fishman, Shim, & Fosket, 2003; Webster, 2002),

or more specific developments in genetics (Franklin,

2001), visualisation (Waldby, 2000), or the internet

(Nettleton, 2004)—have all been forced to struggle, in

one way or another, with the problematic interactions

between two kinds of medical knowledge. The first of

e front matter r 2005 Elsevier Ltd. All rights reserve

cscimed.2005.07.003

ing author. Tel.: +44191 222 7046;

2 6043.

ess: [email protected] (C. May).

these is experiential qualitative knowledge rooted in

clinical experience and worked out in the everyday

clinical encounter, and the second is experimental

quantitative knowledge derived from population studies,

randomised controlled trials and meta-analyses, and

worked out through the production of different kinds of

clinical guidelines for practice.

In the UK, the interaction between these two ways of

thinking about the ways that medical knowledge

informs practice has often been framed in terms of a

contest between individual clinical autonomy and a new

field of evidence based medicine, and this has been

represented both in studies of experiences of clinical

practice (Summerskill & Pope, 2002), and in studies of

doctors’ perspectives on the interpolation of newly

d.

www.elsevier.com/locate/socscimed

ARTICLE IN PRESSC. May et al. / Social Science & Medicine 62 (2006) 1022–1030 1023

codified ‘evidence’ into their everyday work (Armstrong,

2002). At a macro-level the shift to evidence-based

medicine has been understood in terms of the play of

power through the intervention of the state and its

relatively autonomous agencies to regulate medical

practice (Harrison, 1996), which in turn acts as a key

element of policies and practices around the ‘moder-

nisation’ of the National Health Service (Harrison,

1999). This view parallels a growing recognition of the

emergence of steadily more sophisticated and interven-

tionist mechanisms of state intervention and regulation,

what Moran (Moran, 2002) has termed the ‘transforma-

tion’ of the regulatory state from ‘government by

command into uncoupled systems of self-steering’

(p.391). These ‘uncoupled systems’ themselves form

mechanisms of self-surveillance and governance (Daly,

2003), in which regulatory authority is delegated

downwards into different public sector bodies and

responsibility for meeting the demands of new struc-

tures of governance is diffused through networks of

active management rather than traditional patterns

of bureaucratic administration (Kelly, Mulgan, &

Muers, 2002).

Political struggles over the status of evidence-based

medicine (EBM) are only one element of a complex

arrangement of shifts that are currently taking place in

the British health care system and which frame the

production, mediation and effects of knowledge about

health and health care in relation to individuals and

groups. In this paper we argue that these struggles are

about more than clinical autonomy and managerialism,

but also represent struggles over what kinds of

experiences and knowledge patients are authorised to

bring to the clinical encounter, and how these are made

to count.

Our analysis focuses on the apparently routine

practices that surround the management of chronic

illness in primary care, for this is the field in which

contradictory tendencies of subjective engagement and

aggregated abstraction are being worked out. We call

upon a range of theoretical dispositions, from perspec-

tives informed by interactionist (Strauss, Fagerhough,

Suczek, & Wiener, 1997) and Mertonian ‘middle-range’

theories (Reiser, 1978) of the interaction between

technologies and social practices, to more recent

theoretical positions in which technologies and social

practices are understood to be woven together in the

most intimate way (Heath, Luff, & Svensson, 2003;

Timmermans & Berg, 2003a), and theories of discourse

and its production in critical psychology (Mather, 2000).

The paper is divided into four sections. We begin with

the problem of patient-centredness—a crucial recent

ideological move in medicine—and then explores its

consequences in debates about informed and shared

decision-making in the clinical encounter. The focus

then shifts to practices of production of EBM and its

mediation in the clinical encounter. Finally we point to

the emergence of new technologies and systems of

practice which mediate between patients and health care

providers and which reconstruct the patient as a

minimum data set. At the heart of our analysis is a set

of problems about power, knowledge and subjectivity,

and the ways that policies of modernisation bind new

technologies into a new way of framing health care

practice which we call technogovernance.

Problem of subjectivity

A problem for medicine as a general field is what to do

with the patient’s subjective experience of illness, and

how to connect it with medical knowledge and practice.

Since the 1800s, medicine has focused primarily on

underlying organic pathology: shifting attention away

from the patient’s expressed symptoms and onto clinical

signs—initially attending to organic processes and

disease states, but moving steadily towards more

microscopic analyses of the body (e.g. genetics). Jewson

(Jewson, 1976) has characterised this as a changing

‘cosmology’ of medical practice, in which the sick person

disappeared, to be replaced by the diseased organ or

lesion; while Armstrong (Armstrong, 1983), following

more directly from Foucault (Foucault, 1973), has seen

in this reductionist impulse the emergence of a political

anatomy of the body. This notion is particularly evident

in accounts of the professional socialisation of medical

students, which show how ‘proper’ medicine comes to be

seen as biological in its focus (Becker, Geer, Hughes, &

Strauss, 1961; Good, 1994), the patient’s account of

experienced symptoms being secondary to the doctor’s

authoritative diagnosis based on revealed pathological

signs (Hunter, 1991; Atkinson, 1995). Attempts to

expand the conceptual ambit of medicine have foun-

dered (Armstrong, 1987) as organic pathology is

concrete—it is both a ‘fact’ and a ‘thing’ to be worked

on, and thus deceptively seems both asocial and

atheoretical. The world beyond the body is inherently

and obviously social and thus subject to interpretation.

So, when the patient’s subjective experience is consid-

ered, it is often framed as a medicalised problem: for

example, the psychological consequences of surgery

(Jagmin, 1998; Peerbhoy, Hall, Parker, Shenkin, &

Salmon, 1998); or ‘quality of life’ measures that might

explain differential recovery rates (Bowling, 1991). More

complex elements of the patient’s subjectivity can be

delegated by medicine to nurses, who have worked hard

to claim the emotional labour of patient care for

themselves (Davies, 1995).

The reductionist impulse that characterises much

medical work presents a particular problem for

General Practice, which claims a much wider vision of

the patient (Neighbour, 1987). The reductionist medical

ARTICLE IN PRESSC. May et al. / Social Science & Medicine 62 (2006) 1022–10301024

model has poor practical utility in three areas of general

practice:

�
the management of chronic illness, where the focus is
on maintaining and adjusting medical management

according to the social character of the patient’s

world (e.g. diabetes, asthma, arthritis, congestive

heart failure);

�
diffuse symptoms that derive from the social and
psychological character of the patient’s world, that

tend to be considered inappropriate for hospital-

based investigation and treatment (e.g. low grade

depression, fatigue, medically unexplained symp-

toms, chronic low back pain, gastro-intestinal

discomfort);

�
preventative health care, where the focus is on
identifying and motivating ‘at risk’ and ‘risky’

patients to change behaviours and habits prior to

the onset of any organic or psychosocial pathology

(e.g. alcohol, diet, hypertension, diabetes, exercise).

While hospital medicine may have put the subjectivity

of the patient to one side, doctors in general practice

have struggled to make sense of it since before the First

World War (Cox, 1950). In the intervening period,

psychological theories have been formed around pro-

blems that medicine finds compelling, and these have

framed medical thinking about the consultation in

important and powerful ways after the 1950s (Bower,

Gask, May, & Mead, 2001). Over the past 30 years, a

series of key conceptual and empirical interventions

have challenged the doctor-centred model of medical

consultation, emphasising patient-centredness in medical

practice (May & Mead, 1999). Proponents of the latter

stress the therapeutic value of interactional work

through which the patient’s subjectivity may be both

understood and engaged (Platt et al., 2001).

It is important, however, to relate these conceptual

moves to wider structural and policy shifts in the

organisation of health care. Changing social and cultural

concerns, reflected in the emergence of new kinds of

interest groups during the 1970s, supported a shift away

from medical paternalism (Bury, 1998; May, 1992). The

shift from a paternalistic doctor-centred model of the

clinical encounter, to an apparently more democratic and

patient-centred encounter involves the reconfiguration of

ideas about what the work of a clinical encounter is. The

doctor-centred model relied on the epistemological

authority of medical knowledge and practice embodied

in the individual, responsible, doctor (Parsons, 1951).

In the doctor-centred model of family medicine, the

objective of the clinical encounter was the conversion of

subjective experiences of illness, into objective patholo-

gical categories through the discovery (within the

patient) of pathology that accorded with the nosology

of clinical medicine. Once that diagnostic moment was

achieved, then judgments about prognosis and manage-

ment could commence. But more recent modes of

medical thought also rely on these nosological facts

(Osborne, 1998). The patient is still required to form a

narrative of experience of illness, while the doctor

translates this into pathological models. At the point

at which general practice, under the influence of Balint

and his followers (Balint, 1957), stepped beyond the

reductionist biomedical model, to claim a psychother-

apeutic sensibility for the consultation, and the possibi-

lity of a therapeutic alliance—thus opening the way for a

patient-centred clinical encounter—then individual doc-

tor-patient encounters became, progressively, more

inclusive (Gothill & Armstrong, 1999). Understanding

the ‘whole’ patient could be achieved in a longstanding

relationship, in which consultations were specific epi-

sodes of conceptualisation, through particular ways of

reasoning about the problem. In the shift to patient-

centredness, and its associated notions of empowerment

and enablement, real problems emerge in the clinical

encounter (Salmon & Hall, 2004).

The doctor-centred model of practice made no claim to

enrol patients as anything more than the focus of medical

attention. But the impulse to patient-centred practice

does, and it has involved the production of specific

technologies by which this can be achieved. Individual

relations between doctor and patient are now conceived

as a technical problem of practice, which may be resolved

by reskilling the doctor. These skills maybe identified,

studied and audited—diagnosed, even—through the use

of observational instruments (often applied to recordings

of consultations) and questionnaires directed at patients

and peers. Here, ideas about communications skills;

patient-centredness; enablement and empowerment (Ho-

wie et al., 1999); and notions of quality are available to be

mobilised and enforced by state actors and professional

elites as a means of adjudicating on the conduct of the

doctor. Central to this is the quantitative measurement of

the behaviours and interactions to be found within

doctor-patient relations, and the assessment of their

effects. Individuated autonomy is governed and regulated

by these new systems of observation, in which modes of

reciprocal surveillance are mobilised and patients are

enrolled to make judgments about the doctor’s actions.

The assumption is that better communication between

doctor and patient has positive health outcomes, and that

a patient-centred consultation increases patient satisfac-

tion, and that a ‘health gain’ follows from this (Mead &

Bower, 2000).

Negotiating medical knowledge

The shift to patient-centredness opens up heterogene-

ity: patients are no longer construed as specific instances


of a disease to be locally negotiated, nor are they passive

recipients of individualised and authoritative expertise.

Instead they are now conceptually organised as local

negotiators of a problem, able (and expected) to make

choices about its management, express subjective

experiences and wants, and to adjudicate on the quality

of the care they receive. All of this is expected to take

place in condensed time and space—for the average

length of a consultation in British general practice is

somewhat less than ten minutes (Howie, Porter, Heaney,

& Hopton, 1991). The move towards a patient-centred

consultation—in which patients are set up as active

participants in the construction of the problem and in

making choices about its resolution—requires that this

knowledge is made explicit. This has important implica-

tions for the epistemological authority of medical

knowledge and practice, which cannot now rely

completely on either its embodiment in the doctor or

in the doctor’s individual clinical interpretation of

symptoms, signs and their meanings. The point that is

central to this is the sense in which the clinical encounter

has been reframed as a set of negotiations in general

practice’s grand narratives of patient-centredness, since

the very presence of these negotiations assumes a degree

of epistemological authority for the patient’s story.

Crucial to this has been the ways that medical knowl-

edge has been restructured by the development of

professional expertise specifically concerned with the

evaluation of medical therapies and the emergence of

EBM. EBM can be seen as the consequence of a process

that started with the consolidation of the randomised

clinical trial as research technique in medicine—in the

1950s in the US (Marks, 1997) and in the 1970s in the

UK (Harrison, 1996)—and later with the establishment

of the regulatory sciences of health technology assess-

ment and quality improvement studies in the 1980s.

There is now a very large literature that stems from

medical research and health technology assessment, and

that reflects contests about the effectiveness of health

care practices. Such contests are manifest, as Timmer-

mans and Angell (Timmermans & Angell, 2001) show,

in the ways that evidence based practices are reformu-

lating the kinds of uncertainties that doctors encounter

in their everyday practice; and in the configuration of

what they call ‘research based uncertainty’, the hesita-

tions arising from evaluating the worth of the ‘evidence’.

In clinical practice, the ambiguous status of this

population-based medical knowledge does not allow

for a shift towards a procedural mode of diagnosis and

treatment—the ‘cookbook medicine’ of EBM’s critics.

Indeed, although experimental studies seem to show that

guidelines are valuable and useful to doctors (Grol et al.,

1998), and that they guide practices around particular

conditions, there is also evidence that, as a type of

standardisation procedure for clinical work, guidelines

run into difficulties in the individuated encounter

between doctor and patient (Summerskill & Pope,

2002). The collectivised expertise that emerges through

EBM does not seem to ‘fit’ well with the exigent

practices of doctors—it is mathematical rather than

experiential—and it seems to fit poorly with the

individualised heterogeneous accounts and moral re-

sponsibilities that sit within the ‘patient-centred en-

counter’.

The reliance of EBM on the results of clinical trials is

a problem too: these are often seen as a ‘gold-standard’

because of their formal, standardised and replicable

methods, and because they are amenable to collective

assessment and re-analysis through procedures of

systematic review and statistical meta-analysis. The

problem here is not so much the separation of EBM

from practice—but, as Upshur (Upshur, 2001) observes,

the fetishisation of randomisation as scientific method

rather than statistical technique. It is the latter that gives

EBM its epistemological authority, but problems of

accountability also arise—for the methodological pro-

blems of trials and their meta-analysis are well under-

stood (Timmermans & Berg, 2003b). So, the most potent

criticism of EBM within medicine is an epistemological

one, although derived from an understanding of the

everyday difficulties that attend the production of

experimental knowledge (Miles, Bentley, Polychronis,

& Grey, 1997).

The shift to patient-centredness raises problems of

subjectivity, heterogeneity and narrative authority in the

clinical encounter. EBM is one kind of institutional

response to this, because it makes explicit the knowl-

edge, which forms a point of departure for treatment

and management decisions. But it also requires a set of

practices of integration that enable clinicians to draw it

into everyday practice. These practices are both formed

and made visible in recent debates about shared

decision-making in primary care. Here, the emphasis is

on both doctor and patient expressing preferences, and

negotiating an agreed course of action on the basis of

codified clinical evidence. Work has therefore proceeded

that explores the interactional skills and contextual

difficulties that attend these shared negotiations (Barry,

Stevenson, Britten, Barber, & Bradley, 2001; Elwyn et

al., 2001), the problems that emerge within such

negotiations, and their attempted resolution (Gwyn &

Elwyn, 1999). Ideologically, shared decision-making is

located completely within the field of patient-centred-

ness. Bensing (Bensing, 2000) asserts that, ‘the ultimate

goal is the mutual tuning of the doctors’ and patients’

agenda, and reaching a decision both parties feel

comfortable about’ (p. 21). Even so, there are significant

conceptual difficulties about establishing what a ‘shared

decision’ is constituted by in practice, and about how it

may be practically achieved (Stevenson, 2001). As a

technique of integrating evidential and experimental

knowledge about treatment and management decisions,


such a model of practice is vulnerable to contests

between the epistemological authority of the subjective

construction of the patient’s life-world, and the episte-

mological authority of the doctor’s knowledge. To

sustain the latter, while still viewing the patient’s

subjectivity inclusively, some new intervention is needed.

Calculating and presenting risks

To the epistemological and practical challenges we

have described above, we now need to add another

problem. This is that much of what is now at issue and is

not so much the prognostic calculation embedded in the

management of a disease, but rather the calculation of

risks and effects—deploying knowledge derived from

large trials, or from systematic reviews and meta-

analyses—and translating this knowledge about collec-

tivities into an individual plan for a specific patient.

One of the possible embodiments of this problem are

decision-support tools, or decision aids, seen as capable

of being a ‘supplement’ to the existing communication

with the patient (O’Connor et al., 1999), able to ‘help

people make deliberate and specific choices’ about their

treatment options and the possible range of outcomes of

these. This new technology—of enrolment into a

decision-making process—takes a range of possible

forms, including interactive computer programs, audio-

tapes, pamphlets, and group presentations. All of these

are intended to move beyond the ‘passive’ printed

educational material available for patients, and to

integrate them into an active decision-making process

in new ways. Some are intended for use within the

everyday doctor–patient interaction, some outside it. All

are intended to make possible some kind of systematic,

multi-factorial, approach to an ‘optimal’ decision.

Elwyn and Charles (Elwyn & Charles, 2001) outline

the stages and competences of involving patients in

decisions:

[b]oth professional and patient share information

with each other. At a minimum the professional

informs the patient of ‘all’ the information that is

relevant to making the decision, for example,

treatment options and their benefits and risks. The

patient reveals personal information to the profes-

sional, for example, lifestyle, preferences for different

health states, and issues of importance regarding

quality of life (p. 120).

Importantly, the doctor should share evidence-based

information in just the format that the patient prefers.

This offers an individualised context for evidence-based

patient choice, but crucially, the means of delivering it in

a workable way is increasingly found in information

technologies. These can handle information in struc-

tured ways, calculate risks, and specify outcomes. Most

importantly, non-human actors make it possible to

sustain the epistemological authority of both the

doctor’s and patient’s position, by interposing a set of

values defined elsewhere as the structure of the decision-

making process. So, working through a decision-making

tool—for example, a computer program that permits

doctor and patient to make decisions about treatment

choices for people at risk of stroke (Thomson et al.,

2000), or a system that directly connects the doctor to

sets of updated clinical guidelines and authoritative

knowledge (Rousseau, McColl, Newton, Grimshaw, &

Eccles, 2003)—seems to permit a new kind of clinical

encounter, where engaging with a non-human actor

allows them to jointly share uncertainty. In such

systems, the patient’s subjective engagement with

chronic illness is reframed as a set of limited preferences

that can be mechanically elicited, and then acted upon.

As O’Connor (O’Connor, 1999) notes,

Through the development of information technology,

information that once ‘‘belonged’’ to professionals is

now widely accessible. And from work of evidence-

based practice, information about clinical interven-

tions previously ‘‘hidden’’ away in journals on library

shelves has been re-analyzed in systematic reviews

and meta-analysis and repackaged into clinically

relevant formats. Thus the tools to allow patients to

be real partners in deciding the course of their health

care are available and may soon become the norm

(1999, p.5).

It also interposes an external epistemological author-

ity into the consultation: the values and choices involved

have been constructed elsewhere, in relation to an ideal-

type patient, and ideal-type evidence. What this move

also makes possible is the re-situation of heterogeneity

outside of the centre of the consultation: the key account

is that which is formed around the decision-making tool.

All other aspects of the patient’s subjectivity may be

reframed to be secondary to this.

While information technologies intervene to reorga-

nise the subjectivity of the patient, and to respecify the

ways that this can be worked out, new ‘fields’ of

medicine and health care are also indicated in the form

of ‘telecare’ and ‘e-health’ (Cartwright, 2000; Nettleton,

2004). While the web makes possible not only access to

distributed information and expertise but also new

communities in which identities and subjectivities are

negotiable (Nettleton, 2004), in the emerging field of

telecare new methods for decoupling patients’ subjectiv-

ities from clinical encounters are made possible. Telecare

systems for monitoring the health status of people with

chronic and degenerative diseases are now widely

available (Glueckauf & Ketterson, 2004; Louis, Turner,

Gretton, Baksh, & Cleland, 2003). These devices


measure physiological status and other data, present this

data to individual service users, and transmit it for review

by service providers using either mobile or conventional

telephony. They promise accurate self-surveillance, (which

may lead to improvements in compliance with treatment

regimens and users’ expertise in self-care); and remote

monitoring of individual health status by service providers

to enable early intervention and reduce hospital admis-

sions. Moreover, they act in two ways to secure a specific

version of chronic illness management. First, by setting

objective parameters for an exacerbation event—for

example, hyperglycaemia in diabetes, or blood oxygena-

tion in chronic obstructive pulmonary disease, (Mair,

Wilkinson, Bonnar, Wootton, & Angus, 1999; Montori et

al., 2004)—they act as gatekeepers, placing a minimum

data set about the patient in front of the patient’s own

account. Second, as automated devices, communicating

with a base station or call centre they act to form distance

between service users and service providers (May, Finch,

Mair, & Mort, 2005). The distal patient that emerges

within the field of telecare poses additional challenges for

the management of subjectivities within medicine. Much

of this new field of practice is about shifting medicine and

health care away from hospitals and back into the local

community—its proponents make claim to the potential

benefits of moving specialised hospital based knowledge

and practice back into the community through the use of

information technologies.

Technogovernance

A central feature of contemporary modes of govern-

ance is distributed accountability (Newman, Barnes,

Sullivan, & Knops, 2004). In this context, the shift from

doctor-centred to patient-centred individualizing ap-

proaches to the clinical encounter and to shared

decision-making practices within it can be seen a

political, as well as a clinical, move. But the shift to

patient-centred practice brings with it a problem, this is

found in the priority that is given within it to the

patient’s subjective narrative of illness experience, and

which we have framed as a problem of heterogenity. So,

far from intervening directly in the body, or imaging its

interior, these shifts are concerned with framing the

structure and direction of the engagement between

doctors and patients. These are governmental technol-

ogies, intended to guide conduct and so to structure

work. It therefore seems more appropriate to describe

them—following Foucault’s (Foucault, 1986) notion of

‘governmentality’—as ‘technogovernance’. We have de-

scribed three impulses at work:

1.
The codification and representation of objective
experimental knowledge (EBM) about populations

is a point of departure for shared decision-making.

This respecifies individualization by disconnecting

the patient’s experience from knowledge about

effectiveness of treatment.

2.
Non-human actors can be incorporated into the
clinical encounter to decouple experience and man-

agement. New technologies (in the form of guide-

lines, protocols, and decision-making tools) may be

employed to structure the range of possible decisions

in the clinical encounter itself. The patient’s (and to a

lesser degree, the doctor’s) subjective experience is

therefore separated from decisions about the proper

management of a problem.

3.
New practices and technologies are emerging that
aim to distribute accountability beyond the clinical

encounter, and frame the patient as both self-

manager and the source of a minimum data-set

about clinical condition. The first of these firmly

relocates subjectivity in the life-world of the patient,

the second abstracts from the life-world only that

data that is necessary to determine the trajectory of a

chronic illness, analyses this within parameters that

objectively define the point at which health care

interventions might be required, and alerts an

appropriate authority.

The net effect of these shifts is to bring into play new

practices of governance, in which intermediaries are

deployed to discipline and frame the individual sub-

jectivities of both patient and doctor, and these practices

of technogovernance act to distribute accountabilities

and to survey their products. In parallel to this is a

steady trend towards measuring the effects of distributed

accountabilities. So informatics interventions—whether

they elicit preferences, guide clinical practice, or permit

the remote monitoring of the chronically ill—permit not

only a decision, a programme of management, or

parameters of access, but also have embedded means

of adjudicating and reporting on those decisions to

others. They thus act to effect reciprocal surveillance,

and in doing so open the path to a much wider network

of accountabilities.

None of the impulses that are found in the field of

technogovernance are final achievements, for some are

bitterly contested, and all are riven with internal

tensions. Patient-centredness is a problem (Mead,

2002); evidence-based medicine engenders difficulties in

the clinical encounter and is contested as a form of

knowledge in itself (Summerskill & Pope, 2002); shared

decisions are rarely formed in non-directive encounters

(Stevenson, Barry, Britten, Barber, & Bradley, 2000); the

distal patient presents medicine with massive problems

of interpretation and action (Mort, May, & Williams,

2003); and the virtual world of ehealth is hard to

interpret and enact (Eysenbach & Diepgen, 2001). The

implication of this is that technogovernance is itself


profoundly unstable, because its specific elements em-

body these tensions both in their production and their

practice.

In his reworking of the Greek myths, The Marriage of

Cadmus and Harmony, Roberto Callasso (Callasso, 1978)

offers a powerful reminder that apparently specific

histories have multiple beginnings. Our analysis sets out

one such history—how, over a period of two decades,

problems of epistemological authority have emerged in a

particular branch of medicine. But it also suggests

continuity. The problem of objectification in medicine, to

which the patient-centredness movement (and the ‘biop-

sychosocial’ model that underpins it) is a response, brings

in its wake a problem of whose knowledge counts in the

clinical encounter when this focuses on the trajectory of

chronic illness, diffuse problems, and hidden risks. It does

so by a labour of division that makes heterogeneity, and

which makes the clinical encounter itself hard to manage.

The systems of practice embedded within technogo-

vernance constrain heterogeneity by framing the ‘pro-

blem’ of the encounter in different terms—shifting the

question away from localised authority towards dis-

tributed information. These are hybrid medicines, not

only because they consolidate interdependencies be-

tween humans and non-humans, but also because, in so

doing, different, apparently contradictory versions of

medicine are brought together in the clinical encounter.

In these hybrid medicines, the symbolic drama of the

consultation, and of the clinical actions within it, may

now have a second, on-screen script in which the facts of

the case are framed against information about a

multiplicity of cases and possibilities.

Acknowledgements

We gratefully acknowledge the financial support of

the Alcohol Education Research Council (Grant

APP41/2001); Department of Health (Grant ICT 2/

032); Economic and Social Research Council (Grants

L218 25 2067 and RES000270084); European Commis-

sion; National Institute of Clinical Excellence; and

Wellcome Trust (Grant GR068380AIA-HSR). Many

people have commented upon this paper or contributed

to the empirical studies that have informed it. We thank

especially, John Bond, Marie Campbell, Martin Eccles,

Catherine Exley, Ruth Graham, Eileen Kaner, Frances

Mair, Chris May, Maggie Mort, James Mason, Made-

leine Murtagh, Mary Ellen Purkis, Anne Rogers and

Richard Thomson.

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Technogovernance: Evidence, subjectivity, and the clinical encounter in primary care medicine

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