“One must, as far as possible, make science ocular.” –Michel Foucault

It can be argued that in today’s self-service and information-driven economy, the gatekeepers of knowledge have been usurped. The rapid evolution of telehealth, mobile health applications (mHealth), videoconferencing technology, personal medical devices, and telemedicine has transformed the healthcare industry worldwide. There is now less differentiation between patient and user, as well as the professional and private spheres of consumption. According to the US Institute of Medicine, telehealth “has the potential to radically reshape healthcare in both positive and negative ways and to fundamentally alter the personal, face-to-face relationship that has been the model for medical care for generations.”¹ This paper explores the implications that these revolutionary changes have on both patients and health practitioners, addressing whether telehealth has democratized Michel Foucault’s “medical gaze,” since both patient and doctor view the other through a screen.

Current socio-cultural conditions are conducive to the rapid expansion of telehealth because patient-users demand convenience, medical professionals view the field as a way to cut costs and save time, and ubiquitous mobile devices allow professionals to effectively “be in two places at once.” This change towards the centrality of user participation has led to the success and global adoption of mobile technologies and telemedicine, but since the adoption of new technologies is context-sensitive and constrained by the realities of the marketplace, most innovations have been incremental.

Telehealth: Healthcare at a Distance

Today, essentially every domain of clinical application and specialization can—and has been—transformed through technological means. These technological means include the devices and systems used to link two or more sites together to, “capture, transmit, display, and archive clinical data, images and verbal exchanges.”² According to the International Consumer Electronics Show, the mobile health market alone is expected to reach $26 billion by 2017.³

Today’s technologies are less challenging to use and embody higher levels of information exchange. The ease with which people are able to share knowledge in the 21^st century has resulted in the demystification of medical knowledge, closing the gap between patients and practitioners. Ubiquitous mobile technologies enable people to manage their health with much greater autonomy. There are numerous benefits to digital healthcare; however, the consumerization and deterritorialization of healthcare also highlights an ethical gray area that has yet to be comprehensively explored.

The Rise of “Vital Self-technologies”

Digital health is not only trending towards basic care; the consumer market is also experiencing a significant increase in self-diagnostic devices. Digital technology compresses perceptions of time and space and demonstrates the evolving relationship between products and social actors. Design writer and consultant Tufan Orel contends that self-technologies represent a shift from focusing on developing clinical tools for the professional sphere to the private sphere of consumption. Orel writes: “Today’s consumer wants not only diagnostic instruments, but also instruments for health maintenance and self-cure. And what is more important, with the use of certain biological research and laboratory tools, our consumer becomes an active, creative experimenter on him or herself.”⁴ Self-technology development is in its infancy. This emerging product sector indicates a fundamental change not only in the relationship between patients and medical professionals, but also in terms of the patient’s relationship with themselves, their personal healthcare, and psychological well-being.

Self-fashioning Technologies

Technologies are dynamic and change depending on the context in which they are used. Sociologist Deborah Lupton writes, “Technologies bestow meaning and subjectivity upon their users, just as users shape the technologies and give them meaning as they incorporate them in their everyday practices.”⁵ Since these technologies are not passive, but rather active and reactive via feedback systems, technology has become a prosthesis of the body. This impact is not merely physical; computerized devices also shape human consciousness and impact how people operate in the world.

The social shaping of technology manifests itself in myriad ways. Orel asserts that self-fashioning technologies can serve as agents for carrying out experiments on the self. These notions compliment Michel Foucault, whose work was largely concerned with technologies of power, but who simultaneously revealed an interest in what he referred to as “Technologies of the Self.” Foucault analyzed the ways in which the human alters him or herself into a subject. He contended that through complex social relationships of power and domination, the self has been objectified through scientific inquiry and experimentation.

Returning to the medical realm, Dr. Eric J. Cassell asserts, “It is fair to say that many patients believe that it is the test rather than the physician that makes the diagnosis, and the drug rather than the physician that affects the cure.… Consequently, patients have been an active force in the increasing deployment and dominance of technology.”⁶

Michel Foucault and the Virtual Gaze

In untangling the complexities associated with these changes in the health care industry, it is useful to examine Foucault’s work regarding the intersections between power relations and what he called “the medical gaze.” Foucault believed that medical knowledge has been shaped through socio-political relations and that no human body exists outside the purview of medical discourse. According to Foucault, the body ought to be perceived as that which has been constructed through discourse, practice, and the “medical gaze.” This gaze, however, is often fractured, never “seeing” the human being as a whole, therefore, preventing doctors from treating the entire patient.⁷ In many cases, the patient merely becomes a technological object, a scientific entity, and a unit of financial value.

This perspective is valuable when analyzing the rise of telehealth and “vital self-technologies” since these innovations allow laypeople to monitor and regulate their own health; they represent a shift in both the social order and how we contextualize human behavior and autonomy. Within a digital framework, are the patient and doctor functioning off a more equitable foundation? How are medical power and the “gaze” to be understood through the lens of digital technology?

Negotiating the Business of Health

Healthcare is in a constant state of negotiation between doctors and patients. In the information age, these technologies serve as tools through which power is negotiated. It is clear that changing attitudes and practices are largely due to the increasing incorporation of telehealth into the health sector. Two brief examples will be used to illustrate this, the commercial platform, Doctors on Demand (DOD) and “teleabortions.” Both cases raise the question: Who owns the means of healthcare production?

Theologian Elaine Graham writes that technology is inextricably linked to capital: “Technologies emerge from particular economic relations of production, bearing the marks of particular (often gendered) divisions of labor, the objectification of nature, disciplining of bodies, accumulation of capital, and pressures of commercialization.”⁸

This perspective is critical in understanding companies such as Doctors on Demand, which provide live doctor visits over video chat and cell phones. Users of the service can be assessed, diagnosed, and prescribed medication remotely by independent third party professionals who deliver care through the site. It is important to note that DOD does not actually practice medicine or any other licensed profession; it is merely the platform through which various stakeholders are connected. By designing the service in this way, DOD protects itself legally, since, by agreeing to use the service, users acknowledge that DOD cannot be held medically liable. The company treats medicine as a business.

The placement of stakeholders and state agencies are organized very differently for teleabortion. Due to its highly-politicized nature, teleabortions are generally illegal. Telehealth particularly benefits those living in rural areas since telemedicine abortions eliminate any travel-related costs. Most states have already passed laws preventing teleabortions, citing that a medical professional must be in the room while a patient takes the first medication called mifepristone. The woman is (usually) allowed to take the second drug, misoprostol, at home. The widespread ban of teleabortions highlights how power does not belong to doctors, patients, or technology; it is ultimately up to the state to decide how telehealth will be used within state lines.

Virtual Bodies, Emerging Identities

The medical sphere has always used technology to render the body more visible. It is often the image that speaks for the patient. According to Maggie Mort, Tracy Finch, and Carl May, the authors of Making and Unmaking, “Telehealthcare assumes that at some point patients will take on particular roles and functions with varying degrees of agency.”⁹ Teleabortion serves as a particularly useful example because the practice illustrates how technologies are never value-free. Telehealth is infused with notions of identity and governance. It begs the question, what are the politics of telehealth?

This issue of governance leads to a relevant discussion over whether telehealth technologies enable medical professionals to practice a type of personalized surveillance over any patient that has a mobile device. This raises questions such as: What types of social relations, including power relations, are created through telehealth? Does technology construct identity and, therefore, contribute to the production of the citizen in neoliberal societies? Is self-surveillance a natural result of self-technology usage which encourages the user to gaze upon themselves?

Power is diffuse and Deborah Lupton argues that the emergence of mHealth reconfigures the subject of surveillance, thus complicating the concept of the panoptic gaze.¹⁰ Due to social media and emergent technologies, users are also increasingly turning to the web and its countless anonymous followers to manage their conditions, bringing the public into the private realm. This phenomenon begs the question: What body is being produced via telehealth technologies?

According to Gilles Deleuze and Félix Guattari, “desire” is that which impels people to use telehealth technologies and mHealth platforms. In an attempt to produce their “best selves,” many users choose to adopt these mediums and intermediaries. Patients, users, and practitioners have all been reconfigured as a result of technological feedback loops and systems. Although the role of the doctor is more diffuse than it was prior to the emergence of telehealth, today, professionals can access people at all times so long as they are attached to their mobile device. The medical gaze has been transformed into the virtual gaze.

Conclusion:  Managing People, Managing Machines

It is clear that in the 21^st century, the medical encounter has undergone irreversible transformations. Due to ubiquitous technologies, clinicians no longer possess the sole responsibility for determining treatment strategies for their patients. Multiple stakeholders from across the healthcare industry stand to benefit from the continued development of telehealth technologies. However, the future of telehealth and its success will likely depend on how purposefully both machines and people are managed within this new interconnected digital healthcare network. Simply put, digital literacy and health literacy need to be promoted concurrently. Even though digitized systems and devices have been widely adopted, people still have the autonomy to control the implementation and direction of those social technologies into their lives.

Finally, the artificial has undeniably become the medium of the human experience. Given this, the virtual gaze has superseded Foucault’s understanding of the gaze. The answers to the questions raised in this paper will have significant implications for the future design and management of the healthcare industry worldwide. Telehealth is in its infancy, so both doctors and patient-users have the opportunity to ethically evolve the industry. This is a new frontier in health care and recreating the traditional doctor-patient relationship may not be the most useful goal. Instead, the widespread adoption of technology illustrates how new medical infrastructures and relationships are needed in order to more sustainably respond to what is to come.

Endnotes

¹ P. Lehoux, R. N. Battista and J. M. Lance, “Telehealth: Passing Fad or Lasting Benefits?,” Canadian Journal of Public Health 91, no. 4 (2000): 278.↵

² Lehoux, Battista and Lance, “Telehealth: Passing Fad or Lasting Benefits?,” 278.↵

³ “2015 Presentations,” Digital Health Summit, https://www.healthitanswers.net/event/digital-health-summit/.↵

⁴ Richard Buchanan and Victor Margolin, Discovering Design: Explorations in Design Studies
(Chicago: University of Chicago Press, 1995), 79.↵

⁵ Deborah Lupton, “M-Health and Health Promotion: The Digital Cyborg and Surveillance Society,” Social Theory & Health 10, no. 3 (2012): 229-244.↵

⁶ Eric J. Cassell, “The Sorcerer’s Broom,” Hastings Center Report 23, no. 6 (1993): 37.↵

⁷ Arushi Sinha, “An Overview of Telemedicine: The Virtual Gaze of Healthcare in the Next Century,” Medical Anthropology Quarterly 14, no. 3 (2000): 291-309.↵

⁸ Jon Seltin, “Production of the Post-Human: Political Economies of Bodies and Technology,” Parrhesia, no. 8 (2009): 51.↵

⁹ Maggie Mort, Tracy Finch and Carl May, “Making and Unmaking Telepatients: Identity and Governance in New Health Technologies,” Science, Technology & Human Values 34, no. 1 (2009): 21.↵

¹⁰ Lupton, “M-Health and Health Promotion: The Digital Cyborg and Surveillance Society,” 240.↵

Author Affiliations

Mae Wiskin
MA Design Studies alumna, Parsons School of Design