Moral Economy of Medicine Working Group
Annotations from our Discussions… towards a Genealogy of Moral Economies
Thompson, E. P. 1971. “The Moral Economy of the English Crowd in the 19th century”
Past and Present 50: 76-136 [and] The Making of the English Working Class.
In his classic work on the transition to fully modern, industrial capitalism in its homeland,
England, Thompson used moral economy to problematize the autonomy of markets and “the
economic” by indicating its connection to a larger social and cultural context. Thompson argued
that prices, the practical markers of economic value, were not set solely by the market in 18th
century provincial England. Rather prices were hedged by the threat of civil unrest among rural
producers and regional consumers, unrest founded upon conventional notions of a fair price that
afforded subsistence to rich and poor, to producer, marketer, and consumer, to townspeople and
rural folk alike. Economic value had non-economic determinants. And, though these
conventions were of a social order in the throes of change—which is the real story of
Thompson’s tale—they do not disappear in the liberal ideologies of 19th century capitalism.
Thompson recounted the rearguard actions against a notion of “the market” as an institution
freed of its trammels, all the while implicating this very idea of a free market as a legitimating
convention. The economy is born from and borne by its moral authority and political dominance,
values hidden in its fetishization and naturalization.
--Bill Lachicotte
Daston, Lorraine, 1985. “The Moral Economy of Science,” OSIRIS 10: 2-24.
Lorraine Daston’s appropriation of the concept of moral economy describes (past)
scientific practice as constitutive of social fields. For Daston, moral economy has little to do
with markets and prices. It refers instead to “a web of affect-saturated values that stand and
function in well-defined relationship to one another” and partakes of an older, generic notion of
economy as “an organized system that displays certain regularities” (p.4) What counts as
“science” depends upon its transaction of those values to which practitioners are committed. Yet
neither the values nor the practitioners originate in “science.” Rather both are made over by a
social history which distinguishes their peculiarly scientific identities, relationships and
attachments. The moral economy which results from this history of transaction constitutes the
field. It stands within the production of scientific knowledge as well as of scientists.
--Bill Lachicotte
Bourdieu, Pierre. 1996. “Misrecognition and Symbolic Violence” in The State Nobility, pp. 3053. Stanford University Press.
In Bourdieu’s theory of practice, both senses of moral economy can be readily understood in
terms of fields and capitals. Bourdieu’s social theory is a kind of general economics in which
actions are understood as exchanges regulated by and accountable in forms of value, species of
“capital.” Social life is differentiated historically into fields according to specific “rates of
exchange” among the general forms of capital, a process which ordinarily results in a dominant
value specific to, indeed definitive of, the field. Capital proper, that is monetary capital, is
simply the dominant value of the field we call “economic.” This differential dynamic moment of
social life, which creates the “restricted markets” of particular fields, remains integrally linked to
the field of power. I mean “integral” literally for the field of power can be conceived as the
conjunction of fields, the market of markets, in which the general value of “capitals” is set. It is
the realm of the “political economy,” powered by the class struggle, the moving (not unmoved)
mover of modern human history. For Bourdieu, all economies are moral, if we understand them
as matters of value in manifold forms; conversely, all moralities are economic, negotiable
matters of human transaction which transect, in practice, relatively autonomous fields.
--Bill Lachicotte
MEM Working Group Readings 2010-11:
Fassin, Didier. 2008. “Beyond Good and Evil: Questioning the Anthropological Discomfort
with Morals.” Anthropological Theory 8: 4: 333-344.
This article is part of a published “debate” (read discussion) between Fassin and his
colleague, Wiktor Stoczkowski, where they consider the question: “Should anthropology be
moral?” Referencing a well-known earlier exchange between Roy D’Andrade and Nancy
Scheper-Hughes, Fassin calls for a “science of morals” that would avoid both the twin perils of
scientism and moralism. His approach effectively recasts the opening question by instead
interrogating why the discipline exhibits such unease with the topic of morality itself. Noting
that anthropologists generally avoid the formal study of morals (preferring politics) and yet
increasingly gravitate towards research topics through moral indignation, Fassin suggests they
would be wise to open “the black box of self-contentment” to rediscover an analytic mirror.
Relating anecdotes from his work on the charged subject of AIDS in Ivory Coast and South
Africa, as well as youth riots in France, he affirms a need for critical analysis alongside outrage
and recalls E.P. Thompson’s formulation of moral economies. For Fassin a moral anthropology
would “render visible and intelligible moral issues in a cultural and consequently historical
context” and at the same time “should always remain problematic, in the sense that it should
always pose problems to the researcher both epistemologically and ethically” (341). In this
sense the anthropological discomfort with morals could prove heuristic.
Fassin’s article holds direct relevance for the MEM Working group given the latter’s
nominal attachment to “moral economy.” Whether or not one agrees with his formulation, it
poses a useful and provocative general question about the framing of ethical terrain relative to
ethnography.
— Peter Redfield
Lakoff, Andrew. 2010. “Two Regimes of Global Health.” Humanity 1:1: 59-79.
Lakoff observes that global health has emerged as a key term of our contemporary
moment, providing a rationale for a remarkable array of actors and endeavors. His essay
sketches an initial typology of this assemblage by distinguishing between two different
“regimes” that deploy versions of the term, one emerging from security concerns about outbreak
diseases and the other from humanitarian concerns about human suffering. While sharing
overlapping elements vocabulary, the visions and endeavors of these two approaches diverge, at
times quite sharply. Both perceive a “global” field of knowledge and intervention beyond the
established national framing of public health, including the nation state framework of
international health. But the vector of their motive orientation runs in opposite directions:
“Whereas global health security develops prophylaxis against potential threats at home,
humanitarian biomedicine invests resources to mitigate present suffering in other places” (60).
Lakoff illustrates this distinction through contrasting examples. On the one hand we see efforts
to establish a universal surveillance system for emerging infectious diseases through the WHO.
In the case of avian flu this results in American objections to Indonesian efforts to exercise “viral
sovereignty” over samples and Indonesian objections to patented pharmaceutical vaccines
derived from the strain. The dominant ethical stance of such a security approach is ultimately
self-protection. On the other hand we see efforts by entities like the Gates Foundation and
Médecins Sans Frontières to produce treatments for suffering individuals worldwide, all in the
name of a humanitarian version of biomedicine. This form of global health flows around
national health agencies, to “govern through the nongovernmental” (66). Its dominant ethical
stance is that of expressing common humanity. Lakoff closes by noting that while each regime
exhibits its own internal coherence, the two might be viewed as uneasy complements: “If so,
humanitarian biomedicine could be seen as offering a philanthropic palliative to nation-states
lacking public health infrastructure in exchange for the right of international health organizations
to monitor their populations for outbreaks that might threaten wealthy nations” (75).
Lakoff’s article offers the MEM Working group the beginnings of a map for “global
health” and two general moral economies at work within it.
— Peter Redfield
Garcia, Angela. 2010. The Pastoral Clinic: Addiction and Dispossession Along the Rio Grande. Berkeley:
University of California Press.
The Pastoral Clinic is a richly written ethnographic account of heroin addiction in northern New
Mexico’s Española Valley, an area that has had the highest rates of heroin-induced deaths in the United
States since the early 1990s. Inspired by Arthur Kleinman’s (2006) call to study “what really matters,”
Garcia returned to her place of birth to work the graveyard shift in an underfunded detoxification clinic,
hoping to better understanding an epidemic that had become so pervasive that hypodermic needles had
blended into the idyllic desert landscape, as if natural artifacts. The “pastoral clinic” of the book’s
namesake sets the stage for Garcia’s unsettling account of the forms of loss, suffering, and vulnerability
that have become an ordinary way of life for so many in the region. Yet the book is not a clinical
ethnography, at least in the traditional sense. Instead, one of her primary aims is to move between
different sites of analysis and temporal frames to explore the ways in which care emerges in the most
intimate moments of social life. She explains, “It is the pastoral clinic, but the subjects and effects of the
pastoral—as representation, mystification, experience, power, and care—exceed the clinic’s bounds. My
hope is that this approach will lead to a rethinking of old assumptions that operate through standard
approaches to addiction, as well as present possibilities for understanding addiction as a reflection of our
broader world” (31). In addition to referencing a form of salvation-oriented care, the trope of the pastoral
also draws attention to Garcia’s interest in the land itself as a reminder of the historical dispossession of
the heroin-addicted Hispano people.
The book addresses several themes of interest within contemporary medical anthropology, including
discourses of chronicity, the juridical response to addiction, and the increasing devolution and
privatization that have shifted health care responsibility away from the state. What initially captured the
interest of the MEM working group, however, was Garcia’s careful engagement with the topic of care.
Though it remains implicit in much of the text, Garcia’s thinking about care is heavily influenced by the
work of French philosopher Emmanuel Levinas, who viewed care for the Other as the primordial ethical
orientation (see n14, p. 213). Garcia finds that the intimacy and interdependency of human relationships,
especially family relationships, have become an important context for heroin addiction and treatment.
Indeed, Garcia views the clinic itself as an extension of the domestic arena: “in this setting institutional
life was an extension of a broader realm of sociality, especially of family” (62).
In light of the high rates of intergenerational heroin use that Garcia observed, she notes an important
conundrum of care in the face of the increasing failure of state institutions: “In the absence of available
services, the central bearer of responsibility for care is the family. Yet, as this work has shown, the family
is also often the primary site of heroin use. The addict thus confronts a quandary. She must turn away (or
is separated from) her family and toward the institution in the recovery process. But then she is
abandoned by the institution and must return to the family, where her addiction resumes” (191). While
she does not offer any tidy solutions to this complex, heartrending dilemma, the value of Garcia’s work
lies in her careful attention to the ways in which families “conceive of ways to care for one another in a
context where their very relations, and the very struggle to maintain the everyday, are at stake” (203).
-Mara Buchbinder
References cited:
Kleinman, Arthur. 2006. What Really Matters: Living a Moral Life Amidst Uncertainty and Danger.
Oxford: Oxford University Press.
Taylor, Janelle. 2008. “On Recognition, Caring, and Dementia” Medical Anthropology Quarterly
22(4):313-335.
Taylor’s critical analysis of American assumptions about the kinds of losses associated with dementia
pushed our discussion of “care” in new and important directions. This article’s starting point is a
reflection stemming from the author’s personal experiences having a mother with dementia. Taylor
consistently found that the most common reaction she receives when people find out that her mother
has Alzheimer’s is the inquiry, “does she still recognize you?” In examining why people find this question
so significant, she exposes the problems with our tendency to conceptualize “caring” as an attitude held
by discrete individuals who express their regard for others through verbal demonstrations of cognitive
memory. If a person doesn’t remember your name, we assume they do not- or cannot- “care” about
you. Embedded in this question, then, are a series of assumptions about selfhood, friendship, and
notions of care—assumptions that Taylor shows often result in the abandonment and social death for
people with dementia.
Posing the questions, “What social processes are at work behind this constant question about
‘recognition’? Why is it apparently so difficult for people to ‘recognize’—as a friend, as a person, as even
being alive—someone who, because of dementia, can no longer keep names straight?” (324), Taylor
first examines whether philosophy may offer insights into the act of recognition.
Yet most philosophical discussions of the politics of recognition, exemplified in the work of Charles
Taylor and Nancy Fraser, for example, assume struggles for political participation by self-identified
groups, this does not directly apply to people with dementia. Taylor argues, “We may need to stop
looking only to individuals as the bearers of ‘selfhood,’ and start looking more at how ‘selfhood’ is
distributed among networks, sustained by supportive environments, emergent within practices of care”
(326). She finds more insights in Paul Ricoeur’s broad discussion in The Course of Recognition (2005),
which identifies three moments in a dialectic among different semantic clusters of recognition:
recognition as identification of things, self-recognition, and the recognition by an Other. Importantly,
“‘recognition’ changes from the active to the passive voice, as it moves from a cognitive and intellectual
matter to an ethical and political one” (314): if one form involves an active, ‘sovereign self’s intellectual
‘recognition’ of external objects, the other pole involves the passive receipt of ‘recognition’ by others.
Taylor argues that we need to renew our social recognition of those with dementia as an ethical
imperative, rather than visit upon them social death due to their cognitive inabilities. A failure to
remember our names does not, she shows, mean a failure to care.
And her auto-ethnography elaborates on how her mother enacts, practices, expresses, and receives
care-- beyond the cognitive acts of remembering. “’Recognition’ is inseparable from ‘caring,’ and both
can be understood as not just the interior emotional or intellectual states of individuals, but as practices,
particular forms of activity, at once social, representational, and very concretely material” (326). Caring
emerges in Taylor’s account as a form of recognition that involves communicative practices enacting
relationality with others, such as laughing at a joke, reaching out, patting one’s hand, attending to one’s
presence. “These communicative practices, are, I believe, also practices of caring—my mother cares
about smoothness of the back-and-forth flow, takes care to keep it all going, and in doing so she acts in
a caring way toward me and other people around her” (328). Caring gets expressed in “[t]he impulse to
care, the habit of caring, the embodied knowledge of how to take care” (329), caring about and taking
care of details as a way of caring for people: “the work [of] impos[ing] on the resistant matter of her
world an order, at once aesthetic and moral, of evenness, fairness, smoothness, and security” (331) –
multiple forms of selfhood and caring which a focus on cognition and speech obscure.
Taylor thus rejects the assumption prevalent in both everyday and philosophical discourse that “caring”
is primarily an attitude, a “subjective and internal state of mind and feeling of a discrete individual, and
one that is premised on a capacity for ‘recognition’ in its narrowly cognitive sense” (318). The inability
to remember names does not mean that a person with dementia “cannot ‘recognize’ or ‘care’ about
others, but it may mean that other people stop ‘recognizing’ or ‘caring’ about them” (318).
Our discussions included reflections on the difficulty of minimizing an emphasis on the cognitive basis of
recognition; the distinctions between a politics of recognition aiming to gain recognition by others, and
Taylor’s focus on the (political-social) process by which people with dementia lose recognition; and the
strengths and the limits of auto-ethnography for explaining broader trends in society. Additional
musings focused on the ways Taylor’s particular experiences shifted anthropological discussions away
from the labor of health care, and how her insights might be brought to bear on ethnographic work
related to this topic.
Fitzgerald, Ruth, 2008. “Rural Nurse Specialists: Clinical Practice and the Politics of Care”
Medical Anthropology 27(3):257–282.
Inadequate supplies of physicians in rural New Zealand have resulted in a shift of nurses’
professional responsibilities, as locally residing nurses increasingly take on tasks previously
reserved for doctors. Yet this shift is considered problematic by both society at large and the
nurses themselves, for it raises questions about the quality of medicine being delivered and the
integrity of nursing work, understood as providing a distinct form of “care.” Fitzgerald describes
the ways these nurses both “actively police this crossboundary work and labor simultaneously to
shore up their nursing identities” (2008:257). She demonstrates the highly politicized character
of divisions of labor within health care and argues that the study of new types of care work(ers)
represents an important, though neglected topic for anthropological analysis. “The study of the
social organization of clinical medicine is much enriched by paying closer attention to its
interaction with allied health professions and their associated understandings of ‘‘good’’ care”
(257).
Fitzgerald’s article holds relevance for the MEM Working group inasmuch as she
elaborates ethnographically on distinct concepts of ‘‘good’’ care for different professional
groups who collaborate, attending to their “ideological, moral, and technical complexity and the
ambiguous and contradictory meanings that the term holds” (260). She argues that the tendency
of scholars writing on the divisions of labor within medical work to focus on boundary disputes,
can lead them to overlook issues embedded in practice, such as distinct occupational definitions
and ethical imperatives regarding “care.” Drawing on Bourdieu’s concept of habitus to
understand the policing of boundaries that rural nurses engage in, she argues: “If we broaden the
concept of boundary disputes to become the representation of a habitus of care, then ‘‘good’’
care can be understood to be the embodiment of a collective professional memory or history. It is
this memory that actively constrains the workers’ imagination of ‘‘other’’ professional styles of
care while providing them with the endlessly generative individual variations on the professional
theme that marks their own practice (by its demonstrated variety) as truly excellent” (278).
Fitzgerald concludes by advocating for a study of ‘care’ as an emic term “in a
comparative language of practice,” a site where “harried practitioners find a source of ethical
reflection, a purpose in their work, inspiration for their professional identity, and a sense of
pleasure and worth in their embodied competencies” (279).
-Michele Rivkin-Fish
Lovell, Anne M. 2011. Debating Life After Disaster: Charity Hospital Babies and Bioscientific
Futures in Post-Katrina New Orleans. Medical Anthropology Quarterly 25, no. 2 (6): 254-277.
Lovell examines the tensions surrounding the creation of a new biosciences district, GNOBED, following
the closure of Charity Hospital in New Orleans as a result of damage from Hurricane Katrina in 2005. In
an analysis that draws on stratified reproduction theory and the politics of time, she shows how forms of
vulnerability and inequality following disasters are naturalized and reinstated in debates over urban space,
technological investment, and health care as a public good. Lovell examines how different temporal
frames of kairos (a present, ethical urgency evoked through the figure of babies at Charity Hospital),
chronos (referring to future life, or prolonging life through the promise of bioscience technology of
GNOBED), and prolepsis (a rhetorical device used to foreclose debate by speaking as though future
events have already occurred) are engaged in order to shape and inscribe expectations about life and death
in the present and future spaces of the hospital, the city, and bioscience district.
In the controversy over the creation of GNOBED and the restoration of Charity Hospital, the future
orientation and investment in bioscience is contrasted with the present health care needs for poor New
Orleans residents. At stake here is the definition of community, and what counts as serving that
community in terms of health care services, biomedical research, and the use of urban space. Pointing to
the multiple, cascade-like effects of disaster, Lovell shows how existing forms of inequality and access to
health care services bring the closure of Charity Hospital to bear on issues of life for a particular segment
of the New Orleans population. The Moral Economies of Medicine working group found this article
relevant for its examination of how public goods and how forms of life are defined through particular
investments in the present, the future, and medical services research.
--Amelia Fiske