The international growth and influence of bioethics has led some to identify it as a decisive shift in the location and exercise of 'biopower'. This book provides an in-depth study of how philosophers, lawyers and other 'outsiders' came to play a major role in discussing and helping to regulate issues that used to be left to doctors and scientists. It discusses how club regulation stemmed not only from the professionalising tactics of doctors and scientists, but was compounded by the 'hands-off' approach of politicians and professionals in fields such as law, philosophy and theology. The book outlines how theologians such as Ian Ramsey argued that 'transdisciplinary groups' were needed to meet the challenges posed by secular and increasingly pluralistic societies. It also examines their links with influential figures in the early history of American bioethics. The book centres on the work of the academic lawyer Ian Kennedy, who was the most high-profile advocate of the approach he explicitly termed 'bioethics'. It shows how Mary Warnock echoed governmental calls for external oversight. Many clinicians and researchers supported her calls for a 'monitoring body' to scrutinise in vitro fertilisation and embryo research. The growth of bioethics in British universities occurred in the 1980s and 1990s with the emergence of dedicated centres for bioethics. The book details how some senior doctors and bioethicists led calls for a politically-funded national bioethics committee during the 1980s. It details how recent debates on assisted dying highlight the authority and influence of British bioethicists.
Writing in the early 1990s, the prominent British historian Eric Hobsbawm labelled the twentieth century – or at least the period between 1914 and 1991 – ‘the age of extremes’. 1 Having witnessed a series of global economic disasters, ethnic cleansing, two world wars, the foundation and fall of the Soviet Union and the dismantling of pernicious empires – which were often replaced by insular and inequitable nation-states – Hobsbawm saw the twentieth century as devoid of balance, ravaged instead by the failed ideologies of nationalism, imperialism, communism, capitalism, fascism and liberalism. Following previous historical periods that Hobsbawm had referred to in turn as the age of revolution (1789–1848), the age of capital (1848–75) and the age of empire (1875–1914), the short twentieth century was extreme in two ways. 2 On the one hand, it was marked by oscillating moods and events ranging from early twentieth-century catastrophe, through a golden age in the decades after the Second World War, to a period of global crisis and collapse between 1973 and 1991. On the other hand, the twentieth century was characterised by a tendency to classify people, practices, and political systems in simple binary terms, an approach to knowledge and experience that had first gained legitimacy during the Enlightenment. Contrasts were established between seemingly oppositional categories such as: reason and emotion; sanity and insanity; self and other; normal and pathological; capitalist and communist; public and private; female and male; creativity and conformity; individualism and incorporation; static and dynamic; and, as Hobsbawm pointed out, losers and winners. 3
Hobsbawm recognised that extreme social conditions or political positions were not necessarily unbalanced or labile. Opposing forces – such as capitalism and communism during the Cold War – could be inherently stabilising, serving to preserve a precarious balance of power. 4 According to some post-war Western commentators, for example, global stability in a ‘post-crisis world’ could be achieved not only (or even primarily) through political negotiation, but also through the ‘inhibiting nuclear balance of terror’. 5 However, experiences and representations of crises were not necessarily as uniform or universal as Hobsbawm imagined. Republican China, for example, regarded itself differently from the Western world; while European countries might be ‘nations of extreme’, China by contrast was, in its own eyes, a ‘nation of moderation’. 6 Equally, the process of balancing competing interests was neither static nor predetermined, but always dynamic and emergent: the tipping point between seemingly polarised positions was forever shifting in ways that were dictated by socio-economic, cultural, political and environmental conditions. Although disturbances in equilibrium were often catastrophic, they could also be self-correcting. According to Hobsbawm, it was the social and moral crises of the second half of the twentieth century that provided momentum for the regeneration of communities and civil society, or at least for addressing more directly a growing sense of alienation from the modern mechanised world. 7
If preoccupations with moderating extremism and mitigating conflict – or what Greg Eghigian, Andreas Killen and Christine Leuenberger have referred to as being ‘obsessed with the enemy’ – constituted a key aspect of military manoeuvres, political systems and economic theories, they also featured in twentieth-century articulations of personal identity and psychological conflict, although in these circumstances they were often subject to more critical appraisal. 8 In The Divided Self, first published in 1959, the Scottish psychiatrist R. D. Laing suggested that schizoid and schizophrenic individuals were split in two ways: ‘in the first place, there is a rent in his relation to the world and, in the second, there is a disruption of his relation with himself’, leading to ‘despairing aloneness and isolation’. 9 According to Laing, the ‘technical vocabulary’ of psychiatry, which focused on abstract oppositional and divisive concepts such as mind-body and psyche-soma, was unable to account for the complexity or relationality of experience and illness, that is – in Laing's deliberate borrowing from Heidegger – of being in the world. 10 Contemporary fixations with achieving a normal, adjusted state – through medication or lobotomy, for example – were dangerous precisely because they suppressed the human capacity to experience extreme or transcendent emotions. From the perspective of anti-psychiatrists such as Laing, David Cooper and Thomas Szasz, the pursuit of balance or equilibrium constituted not an effective pathway to integration and freedom, but merely a means of ‘acquiring a false self to adapt to false realities’. 11
Laing's position did not hold. In the midst of the global upheavals that characterised Hobsbawm's ‘age of extremes’, personal health and political stability were to be achieved through conformity rather than transgression, by regulating rather than expressing emotions, and by harmonising the interests of the self with those of the state through what Elisabeth Hsu has referred to, in the context of older humoral theories of balance, as the ‘medico-moral nexus of moderation’. 12 In an increasingly individualised, liquid society in which self-interest and self-fulfilment – however desirable – might disrupt social order, balance operated as a ‘catchall term’, 13 one that expressed the need for stability and equilibrium within bodies, families, communities, societies, political systems and global relations. 14 The seemingly distinct domains of enquiry within which balance emerged as a concept were not disconnected: biological models of balance and homeostasis, for example, were employed to justify political arguments for the equitable distribution of resources and information; and political allegiances inflected physiological accounts of adaptation and health. 15 Similarly, although advice to balance marriages or to ensure work-life balance was framed explicitly in terms of enabling personal and family health, individualised techniques for achieving ‘balance’, or at least the illusion of balance, represented another manifestation of contemporary political economy and the disciplinary effects of ‘empowerment’ typical of the neo-liberalisation of everyday life. 16
This collection of essays argues that concepts of balance provided a central – though often diverse and contested – organising motif for a wide spectrum of medical and political projects in the twentieth century. More than this, it proposes that programmes dependent on, and designed to achieve or maintain, balance regularly sought to cultivate specific types of individuals and enrol them in various ways. Even when balance was seen to derive from collective enterprise, ‘balance’ and ‘self’ were closely intertwined. By focusing on health and the body, this volume explores the multiple ways in which institutions, actors and networks mobilised divergent concepts of balance for various ends, investigates how individuals were constituted and convinced to pursue bodily, psychological, emotional, spiritual, social and political equilibrium, and examines the challenges to – and reconfigurations of – conceptions of balance in an age of extremes. Together, the following chapters historicise and complicate assumptions about the links between individualised balance and forms of production or political regimes, and highlight the malleability and multi-valence of balance as a concept. Through its investigations into the diverse life of ‘balance’, therefore, the volume not only contributes to the cultural history of an everyday concept, but also generates insights into the history of health governance and subjectivity and into the close connections between medicine, politics and the regulation of social life.
In her address to the 61st World Health Assembly in May 2008, the Director-General of the World Health Organization (WHO), Dr Margaret Chan, concluded her analysis of current threats to global health with the following words: ‘A world that is out of balance in matters of health is neither stable nor secure.’ 17 Dr Chan was not alone in conceiving patterns of health and illness, the delivery of healthcare services and the maintenance of global security in terms of balance. During the twentieth century it became customary to mobilise concepts of balance and imbalance to capture the multiple dimensions of human, non-human and planetary health. As a growing scholarly literature attests, the language of balance – as well its various synonyms and antonyms – permeated accounts of political stability, the cost-effectiveness of healthcare systems, the distribution of women and men in medicine and other professions, Eastern and Western approaches to the pursuit of happiness and well-being, the diversity and sustainability of ecosystems, and shifting patterns of infectious and non-infectious diseases. 18
In modern Western medicine, balance has been applied quite literally to the capacity of bodies to remain upright and stable in the face of fluctuating internal and external demands. In conditions such as Parkinson's Disease, multiple sclerosis, strokes and Ménière's disease, an inability to maintain or restore physical balance – sometimes configured in terms of hidden physiological disturbances of a vital ‘sixth sense’ – has been regarded as the principal mechanism driving impaired function and the risk of physical injury. 19 Physiologically grounded accounts of balance, or the need to regulate the relationship between the inhibition and stimulation of biological processes, were evident elsewhere across the twentieth century: in studies of homeostasis, which emphasised the importance of the neuroendocrine system in maintaining vital functions; 20 in clinical formulations of the causes and symptoms of asthma, epilepsy and sexual dysfunction; 21 in pharmacological models of conditions such as manic depression (more recently bipolar disorder), which were understood in the interwar period as the product of dysregulation of acid-base equilibrium and subsequently in terms of ‘chemical imbalances’ in the brain; 22 and in approaches to monitoring blood sugar in patients with diabetes, exemplified by the official journal of the British Diabetic Association being renamed Balance from 1961. 23 Although these conditions were often portrayed in terms of natural biological processes, it is important to recognise that the concept of balance in these domains of medicine was imbued with emotional and political significance: as Martin Moore argues, patients who managed to balance their blood sugar levels were regarded (and rewarded) as ‘good diabetics’; and holistic and organismic models of the regulatory processes that maintained physiological balance – or what Walter Cannon referred to as the ‘wisdom of the body’ – provided blueprints for social organisation. 24
While balance helped to constitute modern biomedical understandings of health and disease, it also served to structure treatments. Balance helped to configure practices and treatments designed to reduce pain, improve posture and mobility, and promote health by strengthening or restoring bodily and emotional stability. Some therapies, such as yoga, meditation, herbalism and certain forms of massage, originated in Indian, Chinese and Islamic medical cultures that foregrounded the attainment of balance or harmony as a pathway to health. 25 Others, such as Pilates (pioneered by the German gymnast Joseph Pilates), the Alexander technique (developed in the 1890s), physiotherapy, osteopathy, chiropractic, the use of balance boards, and ‘zero balancing’ (a technique introduced by Dr Fritz Smith in 1973), were rooted in European and North American interest in the capacity for remedial gymnastics and massage therapy to rehabilitate injured servicemen and disabled workers. 26 Although sometimes dismissed as ‘alternative therapies’, or as practices merely supplementary to medicine, such approaches to physical, mental and spiritual health, in conjunction with health education advice to follow balanced diets, drink less and exercise more, were increasingly advocated – and purchased – as part of a healthy lifestyle: improving balance through movement and manipulation was thought to release energy, enhance resilience, promote endurance and productivity, combat obesity and increase a sense of ‘wellness’. 27
Balance also figured strongly in treatments of mental illness. From the 1920s, when Sigmund Freud emphasised the instinctive drive to maintain psychological stability, working through personal crises in order to balance and integrate competing facets of personality became a feature of psychological approaches to restoring emotional well-being, particularly at key transition points in the life course. 28 After the Second World War, clinical and pharmaceutical interest in the biochemical determinants of mental health led to the development and increasing consumption of antidepressants, which were thought to improve mood by restoring the balance of neurotransmitters. Similarly, ‘mood stabilisers’, a term applied initially to lithium but also later used to describe a range of anti-epileptic drugs, such as lamotrigine and sodium valproate, were prescribed to reduce the dramatic mood swings associated with manic depression. 29 Of course, these approaches to mental health have not been uncontested. Clinicians and historians such as David Healy and Joanna Moncrieff have critiqued the manner in which popular notions of balance and stability were exploited by pharmaceutical companies in order to broaden the boundaries of mental illness and create a lucrative market for psychoactive substances. 30 Yet, in spite of opposition to the commercialisation of the language of balance, such explanations for mental illness have persisted, allowing patients and their clinicians to articulate the anxieties and distress generated not merely by physiological changes, but also partly by economic uncertainty, professional insecurity, social turmoil and political instability – that is, by a world that is itself seemingly out of balance. 31
Although they often rejected claims made by proponents of biological psychiatry, psychiatrists interested in the psychosocial determinants of mental illness also embraced a model of mood disorders that mobilised the concept of balance, or what the American psychiatrist Karl Menninger referred to in 1963 as ‘the vital balance’. 32 Menninger's position is particularly instructive. Although he regarded ‘balance’ as a ‘pretty metaphor’, 33 he recognised its power to capture post-war concerns about personal adaptation and social adjustment, about the tensions between conformity and creativity, and about the necessity of ensuring and enabling regulatory mechanisms at psychological, physiological and social levels in order to maintain health and stability. His work also demonstrates the diversity and malleability of notions of balance. Regulation need not mean stagnation, adherence to a fixed norm, or a smooth, untroubled pattern of adjustment, Menninger insisted, but instead encompassed complex processes that oscillated and varied, not necessarily returning to the same steady state, but establishing a new relatively steady state generated by growth, learning and fulfilment. Indeed, for Menninger unbending stability compromised and trivialised life: ‘Life cannot be without stability’, he wrote, ‘but is a completely stable life human?’ 34 In the ‘open systems’ characteristic of living organisms, Menninger argued, the need to adapt in order to survive demanded flexibility and mobility in physiological and psychological systems: ‘A system, to perform work, however, must not be in equilibrium but continually on the way toward attaining it.’ 35
Maintaining some measure of functional balance was regarded primarily as a problem of regulation. According to Georges Canguilhem, physiological regulation was the ‘supreme biological fact’. 36 Regulation also emerged as a key mechanism of adaptation and health promotion in psychosocial and psychosomatic medicine. In both realms, an emphasis on regulation carried political overtones, related to how responsibility for stability was apportioned either to individuals or the state. During the twentieth century, at least in the Western world, it was increasingly individuals who became liable for regulating their behaviour and health, even in countries with state-funded welfare systems. Psychological illness in response to stress, for example, was interpreted as a failure on the part of individuals to effectively manage work-life balance or to cope with fluctuating environmental and economic pressures. Research on both sides of the Atlantic highlighting links between stressful life events, behaviour and illness or between migration and health, 37 as well as studies stressing the importance of perception and coping to the appearance of psychological disturbances, 38 encouraged psychiatrists and patients to regard mental illness as the product of an unbalanced – perhaps decadent or indulgent – lifestyle, in which effective adaptation to the stress of life was compromised. 39 In this paradigm, treatment focused primarily not on restoring biochemical balance in the brain, but on promoting self-help, that is by empowering people to balance their own lives through purchased programmes of cognitive behavioural therapy, 40 biofeedback and relaxation techniques, 41 or mindful meditation. 42
The potency of balance as a normalising concept was not limited to debates about health. In a speech to the Royal Society delivered in 1988, the British Prime Minister, Margaret Thatcher, claimed that ‘stable prosperity’ could only be achieved ‘throughout the world provided the environment is nurtured and safeguarded’. ‘Protecting the balance of nature’, she concluded, ‘is therefore one of the great challenges of the late twentieth century.’ 43 Although Thatcher's commitment to environmental preservation was politically expedient, since she had shown little interest in such issues until the emergence of a global green movement in the late 1980s, her comments testify to growing scientific, public and political interest in reducing environmental degradation, protecting ecological balance, ensuring the harmony and sustainability of the cosmos and preserving human health – interest that had been stimulated in the post-war years by Rachel Carson, James Lovelock and others. 44 While the precise meaning of the term ‘balance of nature’ was rarely explicated and often dismissed as a myth, 45 the notion served to structure political arguments for greater regulation of environmental hazards, improved mobilisation of economic resources, and more integrated, cross-sectoral approaches to global health and well-being. 46
Emphasis on the benefits of preserving the balance of nature was not new. Drawing explicitly on Hippocratic notions of the ‘healing power of nature’, late nineteenth- and early twentieth-century clinicians and their patients increasingly regarded nature as an antidote to the perils of industrialisation and urbanisation. As a number of historical studies have suggested, city-dwellers seeking healthier environments to cure or relieve the symptoms of tuberculosis, asthma, hay fever, bronchitis, rickets and neurasthenia flocked to the mountains and coasts, where the air was supposedly cleaner and lifestyles healthier. 47 During the twentieth century, concerns about the impact of human patterns of consumption of fuel and food sources on environmental sustainability and anxieties about the health consequences of climate change deepened in the light of evidence that global variations in population growth and density were also adversely affecting ecological balance and human health. After the Second World War, researchers such as Paul Ehrlich, Lennart Levi and Lars Andersson insisted that uncontrolled population expansion was significantly reducing the quality of life for people in many regions of the world, largely through rising unemployment, poverty and famine. 48 According to Levi and Andersson, such evidence constituted an important argument for developing an integrated ‘world plan of action’ to redress inequalities in health, reduce the spread of infectious diseases and restore health and happiness to human populations. 49
Similar arguments were evident in debates about global – and indeed cosmic – ecological stability. In the late 1960s, the English scientist James Lovelock suggested that the earth should be regarded as a ‘superorganism’, referred to as Gaia. Lovelock's hypothesis, which emerged initially from the recognition that ‘a stable planet’ was composed of ‘unstable parts’, postulated that the earth and its atmosphere operated as a complex entity that, like individual organisms, sought to maintain the optimal physical and chemical environment for life through the activation of homeostatic or cybernetic feedback mechanisms. 50 Lovelock's approach was predicated, like contemporary accounts of diseases of adaptation, on a belief that dynamic feedback systems intended to maintain functional stability constituted a characteristic feature of all living organisms. The capacity of the earth to adapt to ecological disturbances generated by the production of pollutants, toxins, radiation and waste materials, like the capacity of humans to cope with stressful life events, was dependent on effective self-regulation (or ‘planetary homeostasis’) and the ability to attain new points of equilibrium. 51 Although the Gaia hypothesis was initially received with some scepticism, Lovelock's adoption of a physiological framework began to appeal to scientists, politicians and policy-makers keen to stem the impact of human profligacy on the environment and to reduce the effects of environmental change on human and animal health. The challenge for modern populations, Lovelock insisted, was to raise awareness of human contributions to the balance of nature, to identify the regions of the world (like vital organs in the body) that were most critical to the health of Gaia and to devise strategies for facilitating ecological balance.
Lovelock's formulation of ecological homeostasis, like Cannon's model of homeostasis or Hans Selye's account of stress, represented the reincarnation of ancient notions of balance. The American historian of ecology Frank N. Egerton pointed out in 1973 that the origins of modern preoccupations with the ‘balance of nature’ could be traced to the providential ecology of ancient and medieval cultures, to influential analogies between microcosm and macrocosm, and to long-standing scientific and medical preoccupations with flux, equilibrium and harmony. From the eighteenth century, the work of the Swedish botanist Carl Linnaeus (1707–78) on the ‘economy of nature’ encouraged references to the notion of balance or proportion as a regulatory principle. Although evolutionary evidence of adaptation and diversity among species served to undermine belief in the primacy of stability in nature, early twentieth-century studies of homeostasis, nascent ecological formulations of the relationship between animals, societies and the environment, and United Nations and WHO initiatives to protect the biosphere collectively reinvigorated debates about the balance of nature and its translation into the social sphere. 52 By reconstituting beliefs in the potential for ecological and social systems to maintain functional stability, proponents of the Gaia hypothesis were endeavouring to restore a sense of order and control to a world that, according to many scientists, clinicians, social commentators and environmental activists, appeared to be accelerating towards self-destruction. Attempts to preserve the harmony of the cosmos were another manifestation of the late twentieth-century enthusiasm for regulating behaviour and promoting health in a dangerous and precariously unbalanced world.
Whether restoring balance to the planet or physiological equilibrium to bodies, efforts to regulate social activity in the twentieth century frequently deputed responsibility for action to individuals. Actors as diverse as self-help authors, public health practitioners, patients’ organisations, health and safety regulators and food and pharmaceutical companies all positioned individual subjects as the locus of imbalance and agent for change. To achieve or maintain balance, these actors suggested that individual citizens, consumers or patients needed to develop new relations to their minds and bodies, to how they perceived, represented and conducted themselves. Such ministrations were only partially altruistic, only partially aimed at soothing the inhabitants of a troubled world; they also offered authors, industries and state organisations opportunities to profit from widespread fears about personal and political instability.
According to Eghigian, Killen and Leuenberger, this proliferation of enterprises designed to ‘turn the self’ – the inner lives and self-representations of individual human subjects – ‘into a project’ provided one of the distinctive features of the twentieth century. ‘Individuals across a range of regimes’, they argue, ‘became, in effect, sites for public projects and, at the same time, were encouraged to treat their own lives as projects to be fulfilled.’ 53 But belief in, and practices of, self-reflection and self-regulation were not unique to the twentieth century. In pioneering work, Michel Foucault traced as far back as classical antiquity what he termed ‘technologies of the self’ – ways that individuals ‘effect by their own means or with the help of others a certain number of operations on their own bodies and souls, thoughts, conduct and way of being, so as to transform themselves in order to attain a certain state of happiness, purity, wisdom, perfection or immortality’. 54 Though warning against any teleological story of the Western self, other scholars have outlined how attendance to the self in Europe was slowly disentangled from an understanding of divine or pre-ordained truths from the seventeenth century onwards. 55 Informed by racial, imperial, gender and class hierarchies, ‘modern’ philosophers, political theorists, religious thinkers and artists discussed one's identity, one's perceptions and perspectives, as well as one's station in life, as more malleable than their classical counterparts, subject to both external social and cultural forces and conscious self-directed transformation. 56
Nonetheless, though building on such antecedents, it seems clear that selfhood and subjectivity became objectified in new ways and new settings over the twentieth century, not least in medicine and a proliferation of academic disciplines. 57 Similarly, the self became tied to new political projects, which, as recent scholarship has suggested, often searched for balance as a response to the age of extremes. In The War Inside, for example, Michal Shapira has explored how psychoanalysis provided important perspectives on welfare, the family and democracy in public and political discourse. With particular emphasis on children and the maternal relationship in the formation of reasonable, well-adjusted selves, psychoanalysts argued that state involvement in the well-being of the next generation was essential if democracy, with its checks and balances, could be secured against the extremes of totalitarianism. 58 Similarly, Martin Francis has outlined the limits of emotional economy in post-war British political life. 59 The performance of emotional balance, self-restraint and rationality was particularly important in the Labour Party during the early post-war years, given political and popular connections between a lack of emotional control and the destructive tyranny of Nazism and Socialism. 60
The connection between politics and selfhood has thus been central to recent scholarship. Explorations of selfhood in the twentieth century debated the extent to which the construction of new types of subjectivity, and the cultivation of new views on the self, have been produced through state power, or been connected to programmes for surveillance and control. As Eghigian, Killen and Leuenberger suggest, the human sciences were certainly integrated closely with European state infrastructures over the twentieth century, and both Fascist and communist regimes keenly promoted visions for ‘new men and women’ and sought to root out deviancy in their nascent states. 61 By contrast, recent work on the German Democratic Republic has sought to complicate assessments of the power dynamics and success of state programmes, and to explore the ways in which subjects of new states negotiated projects and shaped their own ‘becoming’. 62 Moreover, as recent sociological and critical theoretical reflections on subjectivity and selfhood in Europe (and its empires) have pointed out, critiques of subjectivity and gender, race, (dis)ability, sexuality, class and intersectionality emerged from – and provided the basis for – new political and social movements with international focus, most notably feminism. 63 Such movements explored how social, linguistic and cultural structures, often supported by the state, shaped experiences and subjectivities, and used reflection as the basis for radical fashioning of the self and progressive collective action. 64
Similar debates about the role of the state have arisen with regard to Britain, particularly in relation to discussions of the ‘psy’ sciences and government of the self. 65 A central aim of the governmentality studies literature has been to move away from traditional state-centric analyses, and instead trace the multitude of ways in which individual conduct has been managed through technologies that link diverse political centres with sites of regulation. 66 By examining the ways that psychological disciplines came to reshape self-understanding during the post-war period, works like Nikolas Rose's Governing the Soul have illuminated the ways in which subjectivities have been historically constructed through the development of new techniques and languages of self. 67 Such accounts have also provided insight into the complex ways that political rationalities of liberalism have become entangled with the lay internalisation of psychological government as well as state efforts to manage the population. 68 However, though this literature has broadened our understandings of the political, as Grace Huxford has suggested, the state has nonetheless retained an important place in analyses of governmentality. 69 Critics such as Mathew Thomson, moreover, have also argued that studies of the ‘psy’ sciences have too often presumed the totalising effects of psychological disciplines, highlighting how a focus on ‘governing at a distance’ has reproduced narratives of control and regulation. 70
In part, at stake in discussions of state and professional power are questions of individual agency that have recurred throughout debates on the formation of the self. Reflections on these questions during the first half of the twentieth century often mobilised concepts of conflict in their explorations. Freud's ego, for instance, was constantly assailed with drives from the id, and the development of other ‘depth’ psychologies fuelled a proliferation of beliefs about the role of the unconscious in shaping and motivating activity. 71 Outside of psychoanalytic discourses, however, concepts of balance and self intersected in interesting ways. In marginal economics, for instance, the rational consumer was one who consciously weighed options and risks in their pursuit of utility maximisation and self-benefit. 72 As Alex Mold suggests in this volume (see Chapter 3), similar autonomous selves were imagined in post-war public health initiatives, where health education came to provide the basis for self-directed action. Of course, twentieth-century economics, like post-war medicine, also incorporated sociological and psychological thinking into understandings of self and agency. 73 John Maynard Keynes, for instance, noted the importance of investors’ ‘animal spirits’ and a ‘delicate balance of spontaneous optimism’ in shaping decision-making, and suggested that ‘in estimating the prospects of investment, we must have regard, therefore, to the nerves and hysteria and even the digestions and reactions to the weather of those upon whose spontaneous activity it largely depends’. 74 Comparable considerations were found in public health programmes, which, as Jane Hand makes clear, incorporated marketing techniques to target the desires of patient consumers. Yet, in neither economic nor public health discourse were actors considered unable to exercise rational decision-making or incapable of self-direction.
By contrast, sociological, historical, philosophical, literary and psychoanalytical researchers have taken different approaches to exploring agency and selfhood in the post-war period. 75 Whether referring to social and economic institutions, discourse or other cultural forms of signification, much of this scholarship has emphasised the importance of external forces imposing on, and constituting, subjects. According to critics, at its most extreme this literature has framed the decentred self as the irresistible product of power, with subjects determined through discourse, ideology or socialisation, and learning to see and relate to themselves and others within the boundaries set for them by political and cultural systems. 76 Yet, as Hall suggests, more optimistic readings are possible. 77 The very categorisation and constitution of subjects that form the grounds for regulation also provide a point of resistance, reshaping and redefinition. Though ‘made up’, in Ian Hacking's phrase, the subject's new existence provides some foundation for self-directed action in ways that might exceed the role and identity afforded to them. 78 Indeed, Dorothy Porter's discussion of Parkinson's Disease in this volume (see Chapter 10) highlights the ways in which newly constituted selves negotiate agency and contest regulation. Whereas scientific and clinical understandings of ‘Parkinson's personality’ have framed creativity in patients as a pathological, iatrogenic symptom resulting from imbalanced treatment, patients have contested this meaning. Instead, they have described their artistic endeavours as establishing calm and transcendence, and some even exceed their recommended drug dosage to enhance their experiences. 79
Contributions to this volume, then, have taken a diverse set of approaches to the question of self and balance, as well as issues of agency and regulation. Nonetheless, a common thread through all the chapters, often (though not always) drawn from a Foucauldian-inspired literature, is an understanding that subjectivities oriented to balance were produced relationally. The ‘self’/‘non-self’ divide – which figured most strikingly as a means of articulating immunological integrity 80 – was constantly permeated; even though they were accorded new forms of responsibility for balance, individuals were rarely left to act alone in projects for balanced selfhoods. A multiplicity of state and non-state agencies were involved in constructing self-balancing individuals, and searches for balanced selves enrolled subjects into new relations not only with themselves and their bodies, but also with a constellation of experts, service providers, family members and like-minded subjects, thus serving as the basis for entering individuals into new forms of sociality. As several chapters demonstrate, relationality stretched to non-human actants. Self-help books, audio equipment and exercise apparatus were just as important to projects of balanced selfhoods as life-writing and records were to the emergence of new forms of self-formation in medicine and the military. 81 Balancing the self in the twentieth century, therefore, did not mean exercising autonomy alone.
Structure and themes
Each chapter in this volume examines a novel instance of the ways in which selves became the objects of technical expertise and political projects for balance, predominantly in twentieth-century Britain. This shared interest in Britain provides a powerful methodological approach for articulating the heterogeneity of balance and its relationship to new understandings and parameters of selfhood. A common geopolitical focus, that is, provides a sense of contextual continuity, enabling each contribution to draw out the ways in which different selves were constituted in relation to balance according to specific constellations of disciplines, techniques of investigation, professional interests, institutional arrangements and subject populations. Conversely, given Britain's broad political shifts from Edwardian liberalism to neo-liberalism over the twentieth century, notably via distinctive blends of conservatism and social democracy, a stable focus also makes it possible to assess the influence of political rationalities on histories of balance when actors and subjects remain broadly similar. Comparative consideration of balance and self in the US – particularly in Chapters 5, 9 and 10 – enhances these reflections, offering the opportunity to examine what was distinct about Britain by contrasting fortunes and tracing connections between sites. Indeed, in this sense, the predominant interest in British developments enables the volume to contribute meaningfully to the social and cultural history of a specific time and place.
In its exploration of efforts to balance the self, the volume is organised in three parts. The first explores the manner in which notions of balance informed public health education campaigns and clinical management strategies that enabled self-regulation in the context of diabetes, alcohol consumption and obesity. At the same time, it examines the ways in which these conditions served to configure and reinforce particular models of the body in balance. The second section reflects on debates about how to address and redress imbalances in diet, levels of stress and work that appeared to impact negatively on health, examining in turn the advice offered to the public by authors of self-help books, the scope of practical guides for relaxation aimed at ensuring balanced lives and the industrial regulation of fatigue in the workplace. The final section explores how experiences and understandings of physical and emotional imbalance and their impacts on both selves and others – in the context of extreme physiological exertion, midlife transitions and emergent neurological disease – served to challenge and reconfigure earlier notions of balance and to provide new tools for managing unregulated bodies and minds. The concluding chapter critically reflects on the methodological and moral dilemmas raised by even attempting to write histories of ‘balanced selves’. As Millard notes, if historians conceptualise balanced selfhoods as historically and culturally situated constructions – subjectivities created (and contested) through power and for political purposes – then we must be ready to historicise our own knowledge, our own subject positions and epistemological foundations so as not to blind ourselves to the gaps and politics of our own work.
In the opening chapter of the first section, Martin Moore explores the ways in which balance was configured in diabetes care between the 1900s and 1960s. Self-care, Moore suggests, was considered an essential element of diabetes management during the twentieth century, and the careful balance of diet and insulin sat at the heart of therapeutic efforts to stabilise blood sugars. However, the chapter argues, glycaemia was by no means the only target of clinical intervention, and self-care formed only one part in a broader constellation of interventions by healthcare professionals, state and patients. Amid growing political and popular interest in affective life, clinicians and a novel patient organisation quickly connected bodily balance with psychological and emotional stability in new ways. Depression, complacency, denial, fear and optimism soon became subject to management in clinical spaces, mutual aid publications and long-term professional–patient interactions, in response to changing notions of health citizenship and self-discipline, and as certain states came to be considered dangerous or beneficial to physiological and political balance. Though focusing primarily on the work of the British Diabetic Association in the first half of the twentieth century, this chapter thus begins to map out the extensive array of tools and agencies involved in constructing selves oriented towards balance, as well as exploring the ways in which the pursuit of balance connected with ideas of gender, empire and shifting political regimes.
Chapter 3 by Alex Mold moves the focus from diabetes to alcohol consumption, and to political and public health efforts to cultivate the ‘sensible drinker’. Focusing on a set of local health education campaigns, an expert committee report on alcohol prevention and a public consultation exercise on alcohol, the chapter highlights how the calculus of balance in relation to individual responsibility and public well-being has consistently been complex. Post-war changes in public health philosophy and practice had constructed individual behaviour as both cause and cure for public health problems. A vision of individual selves as responsive to expert advice was embedded in early Health Education Council campaigns around drinking in moderation. However, Mold argues, policy-makers disagreed on whether education alone could encourage individuals to moderate their alcohol consumption. Though rejected at the time, other approaches – most notably increasing the price of alcohol – were put forward as ways to reduce drinking at the population level. At issue was not simply the capacity of individuals to achieve healthy balance. Policy-makers weighed potential for improved health outcomes alongside individual rights, the social equity of reforms, effects on industrial and employment fortunes, Treasury income and electoral considerations. A growing focus on moderation may have expanded public health's target population, but a reliance on health education and ill-defined concepts like the ‘sensible drinker’ also reflected the ways that disciplinary power could be counterbalanced by political and economic concerns. As Mold concludes, ‘exhortations towards self-regulation were not necessarily a tool of social or political control but could also operate as a way to balance competing interests’.
Jane Hand continues the focus on public health by exploring in Chapter 4 how obesity was visualised and communicated in health promotion campaigns; in doing so, she extends Mold's analysis of contested political programmes to cultivate balanced lifestyles in Britain's populace. Statistical concepts of risk became a central feature of post-war public health, with individual behaviour and consumer choices linked with a diverse array of negative (or potentially negative) health outcomes. As risk was internalised and invisible, Hand argues, health educators turned to obesity as an explicit marker for discussing a variety of ‘hidden’ risk factors and chronic diseases, though especially heart disease. As such, nutrition education campaigns came to use visual images of overweight bodies to redraw the boundaries of what constituted a balanced diet, and therefore what produced the healthy, balanced self. Messages about obesity, dietary moderation and exercise went beyond health, however, often being framed in terms of gendered bodily beauty. By coding disease risk in relation to culturally admonished visual attributes (the obese body) and specific practical preventive measures (such as eating less and exercising more), images thus functioned to articulate specific social ideologies and to promote the idea that individualised health risks could be overcome (at least in part) by complying with health advice. As Hand concludes, though, such official constructions of personal responsibility for balance were consistently disputed and reinterpreted. Personalised health advice was often consumed in disparate ways, with poorer citizens consciously trading health against financial risks. Likewise, by the end of the century mainstream documentaries had begun to connect personal risk with structural imbalances of wealth, and counter-discourses of health reasserted themselves in visually striking terms.
Chapter 5, by Nicos Kefalas, which begins the second section, turns from state-sponsored health education to the contested world of self-help experts. As Kefalas notes, there is a substantial literature considering the emergence of the ‘healthy diet’ as an object of political and medical interest in the late twentieth century. Historians have explored the impact of new food technologies, the rise of consumer culture and the globalisation of food consumption. Yet many of the sources from which lay people obtained information about ‘healthy eating’, including the notion of balanced diets, have not been fully explored in terms of either authorship or readership. This chapter traces the history of healthy eating in the second half of the twentieth century in terms of the advice offered by the authors of self-help books in the USA and the UK. By including American authors, the chapter examines the transatlantic nature of programmes for balance, comparing advice about obesity and dieting, exploring the cultural authority of celebrity dietitians and assessing the degree of knowledge exchange between the two countries. In doing so, it investigates the ways in which readers learned about ‘healthy eating’ on a day-to-day level, generating a more detailed historical analysis of the ‘healthy diet’ ideal and the ways in which the self-help genre contributed to the ‘health manufacturing’ process. Mobilising persuasive motivational language alongside scientific jargon, self-help authors were able to simultaneously promote their own status and appeal to readers’ sense of agency. Analysis of self-help also reveals, however, the controversies associated with self-help and the promotion of healthy balanced diets.
Extending the methodological and conceptual scope of the discussion about regulation and balance, in Chapter 6 Ayesha Nathoo's exploration of ‘relaxed living’ in post-war Britain explores the multi-faceted nature of therapies for bodily balance and the material culture through which they were taken up and incorporated into individual lives. Therapeutic relaxation techniques proliferated in the twentieth century, designed to counteract the myriad maladies popularly associated with the pace and pressures of modern Western living. Practitioners advocated forms of neuromuscular relaxation as safe, effective, drug-free therapies for conditions ranging from high blood pressure to migraine, labour pain and anxiety. However, the therapeutic efficacy of relaxation techniques relied on them being expertly taught, conscientiously learned and persistently practised. This chapter focuses on the pedagogy of twentieth-century therapeutic relaxation methods in Britain, paying particular attention to their material and audio-visual culture. Relaxation instruction and ideology were communicated through numerous channels including self-help books, group classes, correspondence courses, the mass media, teacher training forums, cassettes and biofeedback equipment. As Nathoo notes, the specific techniques of relaxation were embedded in, and contributed to, a larger framework of debates about ‘healthy lifestyles’ that rested on individuals taking responsibility for and managing their own health and well-being. Nonetheless, the chapter makes clear that efforts to construct the self-balancing individual were deeply enmeshed with specific modes, processes and networks of communication. By considering the localised, socio-cultural specificities of relaxation therapies, it is possible to move beyond governmentality frameworks in our considerations of health education, health management and expertise of balance in the post-war period.
In Chapter 7, Natasha Feiner focuses on another dimension of the political tale about regulating health, examining efforts to regulate fatigue among airline pilots in post-war Britain. In the middle decades of the twentieth century fatigue was increasingly understood in terms of balance. If the dynamic equilibrium of the body was upset – by ill health, emotional stress or intensive working practices – fatigue would result. The notion that an imbalance between work and leisure time might cause fatigue (or what later became known as ‘burnout’) was commonplace in a number of industries by 1950. Complaints of fatigue resulting from long working hours and insufficient opportunities for rest were endemic among factory workers, teachers, doctors and pilots. With a specific focus on civil aviation, this chapter explores how fatigue in the workplace was managed and regulated in the twentieth century and evaluates who was considered responsible for monitoring and minimising worker fatigue. In Britain – as in America – civil aviation was one of the only industries to attempt to regulate fatigue after it was implicated in a number of aircraft accidents in the 1950s. As this chapter demonstrates, however, programmes to manage imbalance did not neatly map onto broader changes in British politics. Although regulations limiting working hours and attempting to balance the duty cycle were introduced in the middle and late twentieth century, responsibility for fatigue management ultimately remained with individual pilots. Despite supposed shifts from social democratic to neo-liberal governments in Britain, a liberal, gentlemanly professionalism provided a consistent frame for the regulation of work and fatigue.
Opening the final section of the volume, in Chapter 8 Vanessa Heggie traces discourses about balance in extreme social and physical environments, once more highlighting how considerations of physiological and social balance intersected with empire, race and gender. Human beings arrived at all three ‘poles’ – north, south and the so-called ‘third pole’ on the summit of Everest – in the twentieth century. The medical sciences that enabled and explained such performances were part of a long conversation rooted in mid-nineteenth-century concepts of the milieu intérieur, in which disruption, moderation and rebalance were the crucial functions of living bodies attempting to survive in challenging circumstances. But such activities also called into question other meanings of ‘moderate’ and ‘balanced’, requiring extremely risky human participation and drawing on research – often ethically challenging – conducted through the two world wars. For British and Anglophile participants, balance was also a contested part of their national identity – and extreme performances, whether caused by the environment or the pressure of increasingly competitive and high-stakes international sporting events, could be a mark of both the hero and the foreign ‘Other’. Linking with Natasha Feiner's discussion of dangerous fatigue in the unregulated workplace, this chapter considers the many tensions between balance and imbalance in the context of extreme physiology – in exploration and sport – in the long twentieth century.
Mark Jackson's essay on the making of the midlife crisis in Chapter 9 considers how new subject positions were formed – and imbalances were regulated – through the different modalities of text and counselling in twentieth-century Britain and America. It became commonplace during the twentieth century to regard the age of 40 (or later 50) as a tipping point in the life cycle, a moment when many people could begin to shed the financial, domestic, parental and occupational worries of youth and early middle age and look forward to a more serene and comfortable period of their lives. The belief that life after 40 might present opportunities for, rather than obstacles to, health and happiness was given legitimacy by a post-Second World War popular culture that considered increased consumption and economic growth, at least in the West, as the primary route to self-realisation and emotional fulfilment. Made possible partly by increased life expectancy, the crisis of middle age was recast as an epiphany, a moment of temporary imbalance that was necessary if age-related cognitive and economic decline were to be effectively reversed and individuals inspired to achieve the highest levels of personal satisfaction and emotional well-being. By juxtaposing advice literature on healthy ageing in America, the work of marriage guidance counsellors in Britain, as well as cinematic and literary representations of the ‘emotional typhoon’ experienced during midlife transitions, Jackson argues that the popularity of the term ‘midlife crisis’ lay in its resonance with growing concerns about the collapse of the American dream and post-Second World War anxieties about threats to the stability of the nuclear family. In both cases, notions of emotional balance were reconfigured by obsessions with the ways in which the autonomous individual and the gospel of consumption would effectively restabilise a seemingly unbalanced Western capitalist economy.
In Chapter 10, Dorothy Porter opens up the world of disease categorisation itself to examine how the construction of a specific ‘Parkinson's personality’ not only turned on physiological and therapeutic balances, but also on the balance of patient experience and medical expertise. Parkinson's Disease is often regarded as a condition marked primarily by imbalance and dysregulation, especially in terms of impaired physical balance and reduced dopamine production. However, there are other features of the disease that also reveal much about modern understandings of emotional balance, creativity and agency. This chapter explores the historical construction of a biopsychological model of a pre-diagnostic Parkinson's personality in the late twentieth and early twenty-first centuries. It interrogates historically situated assumptions about character traits that were correlated with neuromolecular variations measured in the brain, exploring these relationships within the history of neuromolecular and biopsychological research on creativity from the late 1980s. The epistemological security of the pathologisation of creativity (as a form of impulsiveness or dysregulation) in the biopsychological model of the Parkinson's personality is examined in the light of patients’ own interpretations of their cognitive experiences and their feelings of dynamic and emergent, rather than static, dimensions of being human. Drawing on specific examples, Porter argues that there was an alternative narrative to the neuromolecular and essentialist notions of disability adopted by scientists and clinicians, one that was articulated by patients in terms of health and creativity, rather than in terms of pathological imbalances in neurotransmitters.
In the concluding contribution to the volume, Chapter 11, Chris Millard provocatively returns to the themes and questions that have been sketched out in this introduction. As the chapters in the volume make clear, histories of notions of ‘balanced selves’ are diverse. Ideas of balance differ across time and cultural space, as do the ways in which balance might be regulated, controlled and incentivised. Among all this variety, Millard's conclusion asks a more general question for those writing histories of balance: how is it possible to historicise balanced selfhood at all? What is the basis for the assumption that human selves might be differently realised, socially or culturally constructed, according to the norms of different times and places? This chapter raises and addresses two challenges. First, it argues that a significant part of the notion of ‘malleable humanity’ comes from early twentieth-century anthropology, especially from work in the tradition of Franz Boas and Margaret Mead. Second, it demonstrates how these assumptions have become visible as a result of a resurgence of neurological, neurochemical and genomic visions of humanity since the late 1990s. If the malleable selves that populate our histories of balance are significantly anthropological, then their relationship with imperialism must be clarified. In addition, as the visibility of malleable selves is related to the resurgence of a new biological vision of humanity, historians also need to clarify and contextualise their own position in this contested terrain.