Contemporary Governance in the Clinical Encounter –
An Asymmetry of Power, Knowledge, and Responsibility
TONY McHUGH BDS, MDSc, PhD, MLitt, MRACDS, FRACDS.
Macquarie University, Australia
The clinical consultation encompasses a two-way gaze in which doctor and patient are essentially object and subject at the same time. Inevitably, however, doctor and patient are governed by a different set of rules and a different set of ‘truths’. Indeed, contained within the two-way clinical gaze, there are distinct asymmetries in power/knowledge relations. Through hierarchical observation, normalising judgement, and the examination, it is the doctor who wields the overwhelming share of disciplinary power, and it is the doctor who is guided by the principles of biomedical ethics (problematic though they may be), not the patient. This calls for added responsibility on the part of the doctor to acquire and develop modes of decision-making understood as the logic of practical, individuated, and value-based knowledge (phronêsis) together with intuitive and habituated skill (mêtis). In other words, studying and knowing ‘truth’ in theory (epistêmê), and having the technical ability to carry out scripted tasks to achieve a practical end (technê), are not enough to attain the goal of becoming an excellent clinician. This does not negate the patient’s freedom to ‘choose’ a desired treatment path within certain constraints, however, while still accepting the inevitability of entering into an asymmetry of power and knowledge, it is the doctor’s responsibility to respond to, and care for, the needs and interests of the patient through an interaction of mutual reciprocity that does not reduce either body to the other or to itself.
The concept of governance, as described by Michel Foucault, involves a network of power relationships, whereby an effect emerges through the modification of individual and/or group actions upon other actions. This Foucauldian idea or art of governing, which he developed particularly in his lectures at the Collège de France in the latter years of his life, is distinct from the commonly held notion of ‘government’ itself, in which the conduct of an individual or population is regulated through institutions and laws. Foucault’s concept of governance—what he refers to as governmentality—involves, through a network of power, a dynamic interplay between three types of relationships: the relations between individuals and between groups; the communication of information through a system of signs; and, the capacity to modify actions (1982a, pp. 217-218). Foucault writes: ‘In effect, what defines a relationship of power is that it is a mode of action which does not act directly and immediately on others. Instead, it acts upon their actions: an action upon an action’ (1982b, p. 789).
An example of this type of governmentality or ‘technology’ of power can be seen in my own clinic. What invariably transpires in the encounter between the patient and myself is a form of relational disciplinary power, termed by Foucault ‘an anatomo-politics of the human body’ (1990, p. 139). In my capacity as the clinician I satisfy Foucault’s three main instruments of disciplinary power, as described in Discipline and Punish (1995, pp. 170-194).
The first of these ‘instruments’ is ‘hierarchical observation’, which is associated with the interlinking of the observer (the clinician) with the site of observation (the clinic) and the observed (the patient). The clinical setting is ‘an apparatus in which the techniques that make it possible to see induce [sic] effects of power [are enacted] … [It is also a site] in which … the means of coercion make those on whom they [techniques of power] are applied clearly visible’ (Foucault, 1995, pp. 170-171).
The second instrument of disciplinary power is ‘normalizing judgement’ (1995, pp. 177-184), which compares individuals with other individuals, patients with other patients, through ‘deviations’ from what is deemed to be ‘normal’, according to discursively determined perceptual standards. Foucault writes:
[I]t [normalizing judgement] refers individual actions to a whole that is at once a field of comparison … It differentiates individuals from one another … It measures in quantitative terms and hierarchizes in terms of value … It introduces, through this ‘value-giving’ measure, the constraint of a conformity that must be achieved … [I]t traces the limit that will define difference in relation to all other differences … [It] compares, differentiates, hierarchizes, homogenizes, excludes. In short, it normalizes (1995, pp. 182-183).
Normalising judgement is, therefore, also prescriptive insofar as by imposing what is ‘normal’ it renders ‘abnormality’ as ‘difference’ in need of correction. In other words, normalising judgement generates a hierarchy and a set of effective punishments and rewards that can be used to coerce individuals within the hierarchy to pursue aggregate ‘normalising’ technologies (ensuring greater macro-homogeneity) and individual normalising or ‘normating’ techniques (ensuring a coexistence of micro-heterogeneity).
The third instrument of disciplinary power is ‘the examination’:
which combines the techniques of an observing hierarchy and those of a normalizing judgement. It is a normalizing gaze, a surveillance that makes it possible to qualify, to classify and to punish. It establishes over individuals a visibility through which one differentiates them and judges them (1995, p. 184) … The examination, surrounded by all its documentary techniques, makes each individual a ‘case’: a case which at one and the same time constitutes an object for a branch of knowledge and a hold for a branch of power (1995, p. 191).
The principle of the examination generates a critical description of the individual in comparison to the accepted norm. It focuses on the ‘anatomo-politics’ of the patient, in which individuality is introduced into the field of documentation, making each patient a ‘case’, an object of knowledge, and a target for power. However, the examination also combines individual control with systematised ‘truth’ producing technologies for ‘the species body’ (these forms of individualised and systemised control are, together, referred to as ‘bio-power’), establishing a comparative standard for the ‘group’ body, whereby ‘species’ bodies come to be defined—according to the concept of the ‘bio-politics of the population’ (Foucault, 1990, p. 139). Population management (bio-politics) and self-management (anatomo-politics), rather than being discrete entities, operate together ‘by continuous regulatory and corrective mechanisms’ (Foucault, 1990, p. 144) towards the notion of what human bodies should be like. Furthermore, the impact of what Foucault calls bio-power can be seen time and time again in my own clinical practice, whereby my patients and I share a system or ‘commonality’ of knowledge that invariably makes for a ‘taken-for-granted’ clinical encounter, and an effective interaction in which the compliance of my patients is generally assumed. In effect, there is an intrinsic link between the patient and the discursively determined objectivised body that is built on the trinity of power-knowledge-‘truth’. In this ‘[w]e are subjected to the production of truth through power and we cannot exercise power except through the production of truth’ (Foucault & Gordon, 1980, p. 93).
This relationship of power-knowledge-‘truth’ is especially evident in the clinical encounter between the cosmetic surgeon and the ‘aesthetically-inclined’ patient, whereby the clinician may have ‘pathologised’ and ‘abnormalised’ a version of—what many would perceive to be—a ‘normal looking’ bodily appearance, and through which she or he may also have pointed out to the patient that options for attaining a ‘better looking’ body exist, explaining that there are means available for the ‘correction’ of the perceived medical ‘problem’ (McHugh, 2013, p. 87).
As such, to enact governance in contemporary clinical practice is to instil ‘action upon action’, in which clinicians and patients participate in relational exchanges of power/knowledge and practice. In this way, technologies of power intervene to bring individual and group bodies into conformity with culturally accepted norms or standards by ‘invisibilising’ technologies of sign systems and production to the point that structures promoting care of the self appear as orthodoxy or as a ‘taken-for-grantedness’. As such, through relational networks of power, individuals and population groups become, at the same time, objects of power, subjects of power, and the means by which power operates (Foucault & Gordon, 1980, p. 98).
The two-way clinical gaze
From my own perspective as a clinician, the relationship between the clinician and the patient is not limited to the clinician-as-subject and the patient-as-object. With relevance to the clinical gaze, Foucault writes:
The object of discourse may equally well be a subject, without the figures of objectivity being in any way altered. It is this formal reorganization, in depth rather than the abandonment of theories and old systems, that made clinical experience possible (Foucault, 1994, p. xiv).
For Foucault, then, the object-as-patient is equally the patient-as-subject; to which I may add, the clinician is also object, as the patient is subject and object at the same time. Essentially, the assumed asymmetry of a one-way clinical gaze, from clinician to patient, needs to be discounted in favour of the likelihood of the patient turning their gaze upon the clinician—searching for empathy, competence, decisiveness, and so forth (McHugh, 2013, pp. 60-61).
The concept of the two-way clinical gaze also challenges the notion of it being an objective diagnostic act of ‘seeing’ alone in two important respects. In the first instance, Foucault states that the gaze ‘contains within a single structure different sensory fields. The sight/touch/hearing trinity defines a perceptual configuration in which the inaccessible illness [or “abnormality”] is tracked down by markers, gauged in depth, drawn to the surface’ (1994, p. 164). The gaze, therefore, rather than being tied exclusively to the act of vision, also includes other functions such as touching, speaking, and habituated and reflective ways of ‘knowing’. Cognitive scientists are likely to refer to this phenomenon as ‘cross-modal perception’ whereby visual images integrate with tactile and auditory sensory input—as well as procedural and conceptual knowledges—in order to situate, understand, and interact with objects of perception (Seyfarth & Cheney, 2009, pp. 669-670).
This then leads on to another depth characteristic of the two-way clinical gaze insofar as the gaze, in the words of Alcoff, ‘can only function successfully as a source of cognition when it is connected to a system of understanding that dictates its use and interprets its results’ (2006, p. 126). In other words, what is ‘seen’ and ‘known’ by the clinician and patient as a result of the gaze is structured by the conditions in which their own subjectivity is constituted. Governance in the clinical encounter, then, becomes a space embedded in a dynamic interplay, not only within medical networks, but also in, through, and between social networks.
An example of power dynamics in social networks, and their influence on clinical perceptions, can be seen in my own periodontal practice. In the year 2008, I saw in the order of 1,000 patients over approximately 4,000 individual appointments—allowing for multiple visits by the same patient. Of those 1,000 or so patients my records show that only 19 individuals proceeded on to surgical treatment for designated ‘cosmetic only’ reasons. All nineteen of those surgically treated by me in 2008 were female. This tendency for females to heavily outnumber males when it comes to corporeal cosmetic modification is also borne out by statistical data compiled by the American Society for Aesthetic Plastic Surgery (ASAPS-Communications, 2009), which states that there were over 10 million surgical and non-surgical cosmetic procedures performed in the United States in 2008, a five-fold increase in the last ten years. Those aged 35 to 50 underwent 45 percent of the total procedures; ages 51 to 64, 26 percent; and ages 19 to 34, 22 percent. Almost 70 percent of all cosmetic procedures involved the face. Surgery accounted for 17 percent of the total, with non-surgical procedures making up 83 percent. Women underwent 92 percent of the cosmetic procedures, men 8 percent. Surgery involving the face included blepharoplasty (cosmetic eyelid surgery), cheek implants, chin augmentations, facelifts, forehead lifts, lip augmentations, and rhinoplasty. These comprised a third of all cosmetic surgical procedures. Non-surgical cosmetic procedures involving the face included various injectables—the most common of which involved neuromuscular blocking agents (such as Botox), which totalled a mammoth 24 percent of all cosmetic procedures—and facial rejuvenation techniques, such as chemical peels and dermabrasion.
My own clinical findings, and the statistics of the American Society for Aesthetic Plastic Surgery, emphasise the highly-gendered nature (certainly in Western cultures) of cosmetic facial modifications in which females, while sharing corporeal commonalities with males, have certain particularities associated with the way their gender is perceived—by both men and women—that have resulted in the aforementioned differences in the incidence of those undergoing cosmetic surgical modifications. These social particularities, which determine differences between females and males—how they are seen, known, and ‘technologised’—require further investigation, which I shall now venture to undertake, utilising a Foucauldian framework.
In the past there have been two dominant feminist approaches that attempt to explain why women seek cosmetic surgery more so than men. The first of these has to do with the perspective that women are assumed to be objectified by men’s standards of beauty through the ‘male gaze’, thereby constructing representations of the female form that are in keeping with the prevailing cultural norm. As put by Kathryn Pauly Morgan: ‘Actual men—brothers, fathers, male lovers, male beauty “experts”—and hypothetical men live in the esthetic imaginations of women’ (1998, p. 334). According to this interpretation, women assess and adjust themselves on the basis of their perceptions of men’s desires or, perhaps more pertinently, to the patriarchal idea(l)s they have internalised. As such, the meaning of ‘perceptions’—which, I contend, are always partial and situated—in this approach is problematised. The second approach is exemplified in the argument put forward by Kathy Davis whereby cosmetic patients are assumed to exercise a notion of ‘choice’ and agency in self-governing and self-directing their treatment decisions, and in which ‘[c]osmetic surgery transforms more than a women’s appearance; it transforms her identity as well’ (2003, p. 75). In other words, Davis contends that by undergoing cosmetic surgery one not only attempts to conform oneself to the discursively determined ideals of ‘attractiveness’ (or as several of the recipients of cosmetic surgery express as a desire for ‘normality’), it is also an attempt to align one’s surface body with the depth body of an ‘obligatory true self’, which essentially (and paradoxically) imposes upon the individual a measure of depersonalised homogeneity (Negrin, 2000, p. 95; 2008, p. 70).
Both approaches, although appearing to be opposed to one another (i.e., an individual being ‘controlled’ vs an individual exercising ‘choice’), treat the body—as Gagné and McGaughey point out—‘as a passive object that is either inscribed by hegemonic norms constructed by men or used by women as a tool in their social construction of a gendered self’ (2002, p. 817). Essentially, these two approaches share the premise that cosmetic surgery is a means by which the individual with—what I term—a ‘difference from’ face has the opportunity to conform more closely to the bio-political cultural standard of the ought face.
Realistically, the objectifying gaze, previously referred to as the ‘male gaze’, comes from many sources, not just heterosexual males. In addition to the male gaze, there are also multitudes of other ‘gazes’: the female gaze, the clinical gaze, the gaze of self-surveillance, the ethnic gaze, the photographer’s gaze, the gaze of the social group, the gaze of the imaginary ‘other’, and so on. All these gazes, aside from being disabling through objectification, are also enabling allowing new norms, fashions, cosmetic surgical procedures, and various other means of self-care to come into view. In other words, technologies of power, signification, production, and self-care—in and through elements of the Foucauldian dispositif (texts, actions, objects)—create norms for the female body and feminine subjectivity to follow. These norms are then internalised, embodied, and maintained. Women who claim to exercise agency in these circumstances embark on cosmetic facial modification procedures based on aggregate and individual ‘discursivised’ knowledges of the norm. These ‘fashioned’ knowledges then intervene to create the conditions whereby those targeted—and statistical analyses previously cited for cosmetic surgery suggest that more females than males fall into this category—bring themselves into conformity with particular standards in ways that are taken-for-granted as being ‘freely chosen’. These ‘chosen’ actions are then perceived as legitimate practices of intervention in which situated knowledges play active and productive roles. As such, so-called ‘empowerment’ is complicitly enmeshed in the practice and institution of cosmetic surgery itself, in which new ways of judging the face to be ‘wrong’ are reinforced by new materials and procedures to make the face ‘right’ (Bordo, 1997, pp. 43-57; Heyes, 2007, p. 93). Put differently, seemingly ‘free choices’ for those who embark on regimes of cosmetic facial surgery are manifest because of particular ‘technologised’ ways of ‘seeing’ and ‘knowing’—epitomised by a superabundance of images of flawless, ‘feminine’, female faces—that are taken for granted as being ‘real’. The (dys-figured) consumer of these technologies is then coerced—and in a sense obligated—into becoming con-figured within regimes of ‘truth’ in which the female face is not only medicalised by technologies of domination and the self, it is refigured and redefined within a fluctuating milieu of mediated instability. As put by Jordan, ‘[t]he plastic body is a contested subjectivity whose meaning shapes and is shaped by the ways that the body can be discussed, by whom, and toward what end, as well as the sociopolitical implications of people seeking to make their bodies conform to an idealized image’ (2004, p. 333). Essentially, I agree with Kathryn Pauly Morgan, when she reasons that what seems to be a reflective decision of ‘choice’, and a matter of self-determination, is often an indication of conformity at a deeper level (Morgan, 2009, p. 58).
Analogous to Foucault’s affirmed technologies of sign systems, power, and production, French sociologist and philosopher Pierre Bourdieu appropriates the aforementioned concept of tacit domination within sociocultural representation as symbolic power or symbolic violence. Bourdieu uses the concept of symbolic power to argue that symbolic systems not only provide the means for ordering and understanding the social world, they also act as ‘instruments of knowledge and communication’ and ‘instruments of domination’ (1991, pp. 164-170). Essentially, symbolic power for Bourdieu ‘is the imposition of systems of symbolism and meaning (i.e. culture) upon groups or classes in such a way that they are experienced as legitimate’ (Jenkins, 2002, p. 104). Power relations are hidden by this accepted legitimacy, which allows for successful imposition and systematic production and reproduction of said social practices (Bourdieu & Passeron, 1990, p. 15). The subtlety of this tactic is the fact that control of an individual’s thoughts and actions is made to appear rational and, in many cases, obligatory. For Bourdieu, ‘[t]he distinctiveness of symbolic domination lies precisely in the fact that it assumes, of those who submit to it, an attitude which challenges the usual dichotomy of freedom and constraint’ (1991, p. 51).
Asymmetry in the clinical encounter
Contemporary governance in the clinical encounter, for clinician and patient, inextricably implicates certain ‘truths’ in knowledge (general and particular) within relevant professional and social fields. However, contained within these relevant networks, there are distinct asymmetries in power/knowledge relations.
An illuminating account of the ‘shared’ (but unequal) doctor-patient relationship is eloquently described by Victoria Pitts-Taylor who, in trying ‘to establish authority over the meaning of … [her own] cosmetic surgery’, gives an informed and personal perspective on many of the fundamental disparities in the distribution of power, knowledge, and ‘truth’ in the clinical encounter. She writes:
I want to be understood … [yet first] [t]he doctors to whom I presented myself as a prospective patient expected a certain set of attitudes about myself and my body … [Second] [w]hile my cosmetic surgery experience is hardly unique, there are aspects of it that are entirely unique because they are rooted in my own body … I do not experience cosmetic surgery in fully translatable terms; and yet in communicating with others I am expected to employ methods of description that make sense to others [and] [i]n doing so, I comply with already scripted codes of meaning that are set out before me … [Third] my self-narration is shaped by the norms that discipline me … such experiences will be translated to individual selves and to the social world in recognizable templates of norms, diagnoses, and social truths … [Fourth] [t]hese disciplinary effects include … the fixing of my subjectivity. I offer myself as a fixed ‘I’ who can explain myself, and who speaks of having intentionality and agency. But although I am expected to define my actions with reference to an ‘I’ that is stable and foundational, I am actually being produced (2007, pp. 176-178).
Pitts-Taylor’s narrative emphatically highlights the asymmetrical nature of the power/knowledge relations between doctor and patient in the clinical consultation. And even though I have argued that each individual is both subject and object at the same time—both sharing commonalities as part of an intersubjective ‘interworld’—I must also stress that each ‘player’ in the encounter (surgeon and patient) is governed by a different set of rules, and a different set of ‘truths’.
Through hierarchical observation, normalising judgement, and the examination, it is the doctor who wields the overwhelming share of disciplinary power and knowledge. And as such, and from my own perspective as a diagnostic and surgical clinician, it is inappropriate to cite the patient’s request (as do many of my colleagues) as being the sole determining factor for this or that procedure to be undertaken. This does not mean to negate or underscore the patient’s freedom to ‘choose’ a desired treatment path within certain constraints, however, while still accepting the inevitability of entering into an asymmetrical power/knowledge relation, it is the surgeon’s obligation to respond to, and care for, the needs and interests of the patient, commensurate with the surgeon’s own value-based principles, through an interaction of mutual reciprocity that does not reduce either body to the other or to itself.
Furthermore, in medico-legal and bioethical circles, it is ultimately the surgeon, who is guided by the commonly cited four principles of biomedical ethics (problematic though they may be) and not the patient—these principles being those of: (1) respect for autonomy (a principle requiring respect for the decision-making capacities of autonomous persons); (2) nonmaleficence (a principle requiring not causing harm to others); (3) beneficence (a group of principles requiring that we prevent harm, provide benefits and balance benefits against risks and costs); and (4) justice (a group of principles requiring appropriate distribution of benefits, risks and costs fairly) (Beauchamp, 2007, p. 4).
And here I draw on the work of Arthur Frank and Therese Jones (2003), who elucidate the following insights. For the patient in the clinical encounter, the question is: ‘How do I, acting as a patient, receive treatment without thinking of myself as, in essence, a patient with all the presumptions of passivity and dependence that requires?’ (2003, pp. 185-186). And for the clinician, the question is: ‘How do I, acting as a health care professional, offer my knowledge and skills to others with the necessary requirement of entering into certain relations of power but still care for my own self and the self of the other?’ (Frank & Jones, 2003, p. 186).
This calls for a responsibility on the part of the clinician to acquire and develop habituated modes of intercorporeal existence and decision-making, understood as the logic of practical, value-based wisdom (phronêsis) and intuitive skill (mêtis). In other words, studying and knowing ‘truth’ in medical theory (epistêmê), and having the technical ability to carry out scripted tasks to achieve a practical end (technê), are not enough to attain the goal of becoming a clinician for whom ‘excellence’ becomes internalised as second nature (Kinghorn, 2010, p. 97).
The good clinician
To cultivate the desired form of practical wisdom in which ‘[t]o act is to act on the basis of some value … [and] to act in ways that exemplify our values’ (Frank, 2004, p. 221), Merleau-Ponty tells us that our body inclines us towards an expertise in those environments in which we consistently take part and practice. He writes:
It is knowledge in the hands, which is forthcoming only when bodily effort is made, and cannot be formulated in detachment from that effort … it is the body which ‘understands’ in the cultivation of habit … [t]o understand is to experience the harmony between what we aim at and what is given, between the intention and the performance—and the body is our anchorage in the world (1962, p. 144).
For Merleau-Ponty ‘habit’ is therefore not a mechanical reflex (like a knee jerk), it is a practical skill that is ‘cultivated’ as a form of training in ‘habitual ways of acting in certain situations’ (Burkitt, 2002, p. 224). It is ‘the grasping of a significance’ (Merleau-Ponty, 1962, p. 143) in which our habitual skills are acquired in the process of dealing with ‘things’ in contextual situations, which in turn determine how those ‘things and situations show up for us as requiring our responses’ (Dreyfus, 2002, p. 368). These habituated skills are then ‘stored’ in the body, not as representations in the mind, but as dispositions which, through imitation and repetition in intersubjective experience, become sedimented styles of being-in-the-world. The interconnection of habit (i.e., skilful action) and perception, through sedimentation, make up what Merleau-Ponty refers to as an ‘intentional arc’ (1962, p. 136). And it is this intentional arc that allows for a certain type of corporeal stability or consistency for dealing with ‘things’ in contextual situations, in which past experiences are projected back into the world, and in which an individual’s actions are, to a large degree, experienced as a flow of habitually created skilful activity in response to the sense of the situation according to the stylised intentional arc. Importantly, Merleau-Ponty’s notion of habituality is not opposed to change. In fact, to maintain stability or equilibrium within a changing environment requires our style of being-in-the-world to change. As put by Jack Reynolds:
[T]he body must change … to stay the same would be to induce instability … The suggestion being proposed is that the mode of being associated with a trained individual—and being trained is a state that the body-subject inevitably tends towards for Merleau-Ponty—is such that it renders the undecidability involved in decision-making an increasingly rare state’ (Reynolds, 2002, p. 457; 2004, p. 92).
Cadwallader refers to this process of changing the style of being-in-the-world as ‘stirring up the sediment’ (2010, p. 513). As Merleau-Ponty puts it: ‘By taking up the present, I draw together and transform my past, altering its significance, freeing and detaching myself from it’ (1962, p. 455). In other words, just like an expert driver of a motor vehicle, or an expert chess player, or an expert surgeon, or an expert diagnostician, or an expert teacher, or an expert dancer, the body inclines us towards a skill or expertise in those environments in which we consistently take part and consciously practice so that it becomes ingrained as second nature. Reynolds explains that ‘[o]n mastering a technique, an individual can become accustomed to a situation in such a way that they “understand” how best to decide’ without prolonged decision-making (2002, p. 460; 2004, p. 96).
For the ‘good’ clinician, what were once consciously performed procedures aiming at clinical excellence, through prolonged practice in an embodied context, have become habituated into ‘excellent’ practice as second nature. In a similar manner, the ‘not so good’ clinician, who consistently stylises poorly thought-through actions, is eventually habituated into a regimen of poorly enacted practice. However, as I have alluded to, change is still possible for the clinician who aspires to excellence as second nature in practice by ‘stirring up the sediment’ with a view to reworking habituated activity in a positive manner and by restylising professional modes of practice. Once the correct habitual practices—which comprise not only technical, but also virtuous dispositions—are in place, the clinician is, in a sense, freed up to devote more considered decision-making (i.e. problem or puzzle solving) through conscious reflection, to those situations which demand thoughtful invention and tactical strategising of a more complex nature. And even in those times when reflective deliberation is usually not required, but where the clinician’s faculties are compromised—through stressful situations, or where fatigue is a factor—excellent habituated practices are more likely to result in the appropriate decisions being made, and the correct technical procedures being performed. Clearly, in clinical practice, explicit instructions contained within the four principles of biomedical ethics listed by Beauchamp, or the ability to carry out a technical procedure according to a ‘how-to’ recipe, are no substitute for the ability to respond to unique and unpredictable situations that call for knowledges in the form of phronêsis and mêtis, both grounded and constituted in and through habituated styles of being-in-the-world.
With the help of the works of Foucault, Merleau-Ponty, and Bourdieu I have argued that, while contemporary governance in the clinical encounter is a shared relationship through mutually overlapping and lived commonalities between clinician and patient, it is inevitably an unequally shared relationship insofar as the rules that govern ‘truth games’ for each specific ‘body-in-situation’ in the relationship differ and are continually in a state of flux. Rather than thinking about the patient, I have argued that the clinician should be thinking with the patient in a relationship in which—because of the asymmetrical distribution of power/knowledge afforded the clinician, in addition to the problematic guiding principles of biomedical ethics—the surgeon must accept the major portion of the responsibility for any procedural action taken, or not taken. Through an appraisal of the acquisition of habituated skills for ‘excellence’ in clinical practice I have argued that studying and knowing ‘truth’ in medical and dental theory, and the following of uniform rules to complete a ‘scripted’ technical task, are no substitute for acquiring the additional knowledges of phronêsis and mêtis, which are themselves grounded in habituated practical experience.
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 Foucault proposed two dimensions of his notion of bio-power. One pole, starting in the seventeenth century, focuses on the ‘anatomo-politics of the human body’, the ‘body as a machine’, by seeking to optimise the capabilities of the human body, enhancing its economic utility and, at the same time, ensuring its docility. The second pole, formed somewhat later, focuses on the aggregate body, the species body, ‘the body imbued with the mechanics of life’. In other words, the second pole is one of ‘regulatory controls: a bio-politics of the population’ (1990b: 139), in which there is a diffuse mechanism of power relations concerned with the promotion of, and intervention in, human life. Both dimensions of power in the Modern era are powers of ‘objectivization’, but they also provide the potential for subjective action in relation to a discursively determined corporeal model or norm.
 Foucault, in Technologies of the Self (1988, pp. 16-49), outlines four major discursive and social ‘technologies’—those of ‘production’, ‘sign systems’, ‘power’, and ‘the self’—each of which he describes as a ‘matrix of practical reason’ that implies some form of training. The interaction of Foucault’s four listed technologies implicates reciprocity between the attainment of knowledge and the practical application of that knowledge.
 Oral plastic surgical procedures were carried out on several other patients related to pre-prosthetic requirements and the repair of tissue anomalies caused by disease and/or traumatic injury.
 Virginia Braun contends that ‘choice’, agency, and obligation are enmeshed. She argues that ‘[i]n a context where the individual should be a (self-improving) agentic subject, choice rhetoric simultaneously promotes … consumer ‘choice’ to ‘improve’ (Braun, 2009, p. 244).
 Negrin points out that ‘while one should avoid being overly dismissive of the reasons people give for their actions [in undergoing cosmetic surgery], at the same time, it is equally problematic to accept such accounts uncritically’ (Negrin, 2004, p. 567).
 The methodological function of the dispositif is to allow Foucault to bring together, to order or to arrange, a whole set of heterogeneous elements—some of which are textual and others non-textual, i.e., language-based and non-language-based—to analyse how their interplay and connections result in historical formations that are never constant, or pre-ordained.
 Merleau-Ponty refers to as an ‘interworld’ (1962, p. 357), whereby individuals share an overlap or commonality between their perceptions and intentions.
 Knowing what and why (epistêmê), or knowing how to craft, or to fashion (technê) according to a set of rules and regulations, is no longer sufficient for a full understanding of embodied social practices. What is also required is a pragmatic knowledge in which there is a sense of value-based action in the dynamic process of corporeal interaction; a knowledge which is ‘singular’, ‘idiosyncratic’, and which is ‘generated in the intimacy of lived experience’, and ‘an analysis of values’ (Baumard, 1999, pp. 53-54; Flyvbjerg, 2001, pp. 56-57). The ancient Greeks referred to this form of knowledge as phronêsis. In addition to knowledge as phronêsis, ‘specific situations’ in everyday clinical and social practices are intuitive and ‘tactical in character … these “ways of operating” [are called] metîs’ (De Certeau, 1988, p. xix).
 This is not unlike Foucault’s reference to the habituated aspects of meletê or meditatio (an exercise of self-care or training in Greek Antiquity) involving ‘not so much thinking about the thing itself as practicing the thing we are thinking about … ensuring that this truth is engraved in the mind in such a way that it is recalled immediately the need arises … making it a principle of action’ (2005: 357).