Health care and the right to be responsible.

Associate professor of sociology at Concordia University

“I really should be taking better care of myself.” Who hasn’t thought that at least once in the past year? (Month? Week?)

In Canada, where I live, government surveys have found in 2014, for example, that 72% of those responding thought there was something they should be doing to live more healthfully – an increase of 13.9% since 2001. Seventy-seven percent planned to do something to improve their health, such as reducing stress, changing their eating habits, or getting more sleep and exercise – another increase (9.5%) from 2001. Still, many of the survey respondents were doing more than just feeling guilty or thinking about living better; 59% of those responding to this 2014 survey had actually done something to improve their lifestyle, up from 54% in 2001. It is clear from these statistics that healthism, an elevated consciousness about health, lifestyle, and related practices of risk and disease prevention, is on the rise.

While on the surface this might seem like a positive development – who can argue with trying to be healthy? – healthism also has a tendency to locate responsibility for optimizing one’s well-being squarely on the shoulders of individuals. Or, to put it another way, it has a tendency to let the State off the hook for its part in looking after its citizenry. In fact, what we have been witnessing is a real shift in recent decades toward greater and greater individual “responsibilization,” where we – me, you, Grandma – are increasingly charged with looking after ourselves with less and less help or support from our governments.

As a Canadian, I enjoy the benefits of a socialized health care system, but even so, it is a society within which this imperative of individual responsibility to my fellow Canadians consistently figures in, say, health promotion and popular lifestyle rhetoric. For example, a recent health column in a popular women’s lifestyle magazine declared it possible to “retrain your brain,” claiming that unhealthy habits can be fixed simply by “changing your perspective.” If your bad habit is that you “often put off exercise,” you just need to “choose more positive online influences.” If your bad habit is an inability to “stick to … healthful eating goals,” then you just need to “predict your feelings about food” before you begin eating. Exhorting individual readers to become entrepreneurial self-managers and take responsibility for the state of their lives, the column goes on to list a series of other personal weaknesses and their quick fixes, all of which boil down to the reader’s good and bad choices and her ability – read: obligation – to conduct herself, her life, more responsibly for the good of all of Canadian society.

And this is where biocitizenship comes in. “Biocitizenship,” a particular mode of living whereby one achieves belonging in society through accepting this kind of individual health responsibility, has emerged in these neoliberal times as a new way of enacting one’s good (and worthy) citizenship. That is, through engaging in normative practices of self-care – making the “right” kinds of lifestyle and medical choices – modern citizenship in the West has become a kind of biological project that depends upon individuals fulfilling their responsibility to the rest of society by accepting and carrying out the responsibility to care for the self. More and more, we find ourselves morally and socially obligated to be proactive about our health risks, whether it be eating right, exercising more, quitting smoking, or screening for genetic disease potential. In this context, responsible citizens engage in self-care, for the good of all. Good (bio)citizens are healthy citizens who do not use up too many health care dollars by having costly health problems they could have prevented if only they’d looked after themselves better. In some instances, would-be biocitizens might even seek legal recourse when they perceive that their right to be responsible has been denied.

As a fairly recent development since Thatcher and Reagan came to power (in 1979 and 1981, respectively), the neoliberal trend toward individual health responsibilization illuminates the need to understand how individual freedom figures in this milieu as a kind of “unfreedom,” by which I mean the capacity, or even the duty to act that, given its regulative moral undertones, is not really very free at all. And as the US stands at the precipice of repealing the Affordable Care Act, never before has this question of individual health responsibilization been more pressing.

On the surface it may seem a moot point in the context of a multi-payer privatized system such as that of the US, but the broader push toward responsibilization plays a key role in contemporary neoliberal governance and is critical for understanding the looming implications of Trump’s plan for American health care. His intentions and politics would appear to represent the end of neoliberalism as we know it, but if his reckless approach to immigration is any indication, it would also appear to be the beginning of something far worse, where for so many who stand to lose their coverage (if they even have any), the possibility of achieving citizenship – biological or otherwise – will prove impossible.


Shelley Z. Reuter is author of Testing Fate: Tay-Sachs Disease and the Right to be Responsible and Narrating Social Order: Agoraphobia and the Politics of Classification. She is associate professor of sociology at Concordia University.

Testing Fate illustrates how diseases become racialized, how racializing them supports political projects, and how the medical profession has been instrumental in racial formation.”
—Dorothy Roberts, author of Fatal Invention

“Shelley Z. Reuter offers a thoughtful, thorough, and sophisticated analysis of themes of modern biocitizenship and belonging refracted through a historical case study of Tay-Sachs disease.”
—Jonathan Kahn, Hamline University

“As she tells the fascinating and important story of Tay-Sachs disease, Shelley Reuter skillfully reminds us of the tight links connecting our concepts of disease to visions of belonging and otherness, selfhood and social responsibility.”
—Steven Epstein, author of Inclusion

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