Terminal Neoliberalization of Care

An exploration of the neoliberalization of healthcare is engineering terminal outcomes and rejecting the possibility of treatment

“In the serene world of mental illness, modern man no longer communicates with the madman: on one hand, the man of reason delegates the physician to madness, thereby authorizing a relation only through the abstract universality of disease; on the other, the man of madness communicates with society only by the intermediary of an equally abstract reason which is order, physical and moral constraint, the anonymous pressure of the group, the requirements of conformity.” — Michel Foucault, “Madness and Civilization”

Terminal anorexia is a debated diagnosis characterized by a refusal to eat, drink, or take medication leading to death. The diagnosis is not recognized in the DSM or ICD and is still being researched, but typifies the kind of mental health condition borne of postmodernist influence on mass psychology of individual worth. The diagnosis of terminal anorexia reflects, as I said in past writing of such diagnoses from western liberal thought, a postmodern view of public health as an individual burden, rather than a systemic issue; exacerbated by the current capitalist and postmodern cultural climate, this perpetuates inequality by creating a culture of victimhood and discouraging personal responsibility. In this context, conditions like anorexia are not terminal in and of themselves, but become so when coupled with austerity and neoliberal healthcare policy. The influence of the neoliberalization of healthcare has resulted in heightened inability to get treatment for psychiatric conditions which is now more difficult than ever and more conditions, consequently, worsen and become fatal, rather than being inherently terminal; this is the symptom, but an objective holistic understanding of the system, outside of the individual experience, within which it can appear to be a validating diagnosis, draws a straight line back to the pernicious effect of capitalist thought on healthcare.

Postmodernism has been a highly debated and often criticized movement in various fields, including economics, but can be applied using this framing to understand how it would impact healthcare in this context; Marxian economic reality is almost entirely, on a conceptual level, fixated on what is value and how it is derived and what is material and immaterial, the latter of which is almost entirely what postmodernism seeks to enshrine as equally valid and real to hold as a law of nature — this is also true of diagnostic medicine; a diagnosis that is controversial for the conclusions it draws is wrestling with the metaphysics of what words like “terminal” are even supposed to mean when a condition like “terminal anorexia” refers to mortality rather than the inherence of a fatal outcome, instead short-circuiting the flattening of the latter into the former for the purposes of, and I’ll discuss this shortly, expediency.

Postmodernism’s rejection of objective truth and universal values has been seen by some as a threat to the validity of empirical research and scientific progress; some economists have used postmodernism as a framework for analyzing the impact of cultural and social factors on economic phenomena, particularly in the context of urban design and planning, and when viewed from the perspective of a materialist, this is the material fallout from the enforcement of postmodernist thought as the gatekeeper of to whom capital belongs and is accessible to, the question of alienation of labor aside for a moment for the purpose of demonstrating the harm done in material ways through social standards enforced on an immaterial basis.

Under capitalism, healthcare is often viewed as a commodity rather than a human right. This has led to the rise of neoliberal policies that prioritize individual responsibility and austerity measures, rather than addressing systemic issues that contribute to poor health outcomes. In this context, those suffering from terminal anorexia are often blamed for their condition, rather than recognizing the systemic factors that contribute to it. This perpetuates a culture of victimhood that discourages personal responsibility and undermines collective action to address social determinants of health. This is the argument put forth by materialist theorists like Michel Foucault and Franco Basaglia. They argue that the medicalization of mental health conditions masks the social and economic determinants of illness and promotes a culture of dependency on healthcare institutions, which under neoliberal policies, prioritize profit over public health that only serve to exacerbate these issues by cutting funding for social services and further expanding social inequalities.

To discuss the problems with the diagnosis itself, with this social context in mind: The current literature suggesting it is controversial because it isn’t usefully scientific in any productive way. These outcomes for conditions like these, studies suggest, cannot be predicted at diagnosis-time, even for conditions prone to sustained relapse, therefore, classifying it as terminal, even if the probability exists of death, is not truly possible in any non-rhetorically misdirected way.

Foucault argued that modern medicine is a form of social control that reinforces the power structures of capitalism and perpetuates inequality. Similarly, Franco Basaglia, an Italian psychiatrist, argued that the medicalization of mental illness serves to justify the exclusion and marginalization of those deemed “mentally ill,” particularly those who challenge the status quo. The secondary issue with this diagnosis is a social one: most literature in support of this diagnosis seems to be thinly veiled bad faith defenses of interventions like “Medical Aid in Dying” (MAID) (basically, one of many regional terms that are shorthand for assisted suicide) as some kind of empowering and validating forgone conclusion despite evidence that you cannot predict the outcomes in this way that would justify it — again, this is a situation where affordable access to quality care and expanded public health apparatuses could have treated a condition that only becomes terminal if treatment fails, something that can only be predicted from the outset if a provider admits quality treatment isn’t going to be delivered, and the reasons this would occur are, again, social, not medical or biological.

This provides the basis for an argument that this diagnosis and the gateway it provides as a runway for eugenic expediency, as some have argued regarding MAID, the question of autonomy aside for a moment where it might be justifiable or truly terminal, he reasoning behind this argument is that MAID is often framed as a way to “end suffering,” but this framing is a complex question of bioethics and can mask the fact that many people with disabilities are not actually suffering and would prefer to live with their conditions, which some argue, is only made more difficult by a commitment to a status quo that excludes accessibility as a design principle and social consideration for the population. Additionally, there is concern that allowing people to choose death rather than living with a disability that otherwise would not necessarily culminate in death could contribute to a culture that devalues disabled lives and reinforces ableist attitudes, essentially enshrining in public consciousness that the measure of quality of life is the ability to be of service as a worker, that being the measure of productivity. Critics of this argument point out that MAID is voluntary and only available to people with a “grievous and irremediable medical condition,” which means that it is not being used to target specific groups of people for elimination, despite the literature on terminal anorexia proposing exactly this. Nevertheless, the debate around MAID and eugenics highlights the need for careful consideration of the ethical implications of end-of-life care, and in this situation, this is an unforced scenario that speaks to one social cause that is unresolved by this outcome; it essentially enshrines capitalism’s right to engineer bad health outcomes and attempts to legitimize this condition as a constant by proposing a diagnosis like this one.

It being impossible to predict outcomes in a way the existence of this diagnosis suggests, upon further reading into this literature, at issue is again actually postmodern response to the structural issue of declining standards & availability of psychiatric care under capitalism: Basaglia and Foucault have argued against the traditional psychiatric diagnosis, and in particular under this brand of neoliberal capitalist thought, which has reached a terrifying peak of influence over public health in the present day, as they believe that it is a tool of social control rather than a scientific method of treating patients. They emphasize the importance of treating patients as individuals rather than diagnosing them based on their symptoms. This approach is similar to consumer rationalization, where the goal is to diagnose the largest number of people without regard for accuracy or individual health factors. This practice can cause mass illness and poor health outcomes on the community scale, emphasizing the need for more individualized and holistic approaches to mental health care. Rather than anything substantive about how eating disorders develop or proliferate or are treated (other than the resource constraint causing cases to become life-threatening and sometimes fatal, which is again, market austerity making treat-ability worse), because this does not represent anything novel about the condition itself, we need to grapple with the fact that these conditions becoming less treatable absent that austerity would make any more suitable or outcomes any better, just short-circuiting the process of various modes treatment without real assessment of how “terminal” terminal means, and if this is a feature of the condition, or a condition of the society we inhabit.

To use an applied example of this interplay and the erosion of public health due to an erosion of collectivized incentive that is very likely to produce a lot of these outcomes where only forced by austerity, my own state: In the 1950’s and early 1960’s, the state government of Iowa led an initiative (a full decade before, and surpassing the standards of, Medicaid’s Early Periodic Screening, Diagnoses and Treatment policy) to address laborer mental health issues through the construction and funding of psychiatric facilities and availability of crisis resources. Decades of austerity measures over the following decades resulted in a number of facility budget cuts, and ultimately the closure of two of Iowa’s four mental health hospitals by 2015. Related services like mental health wards, inpatient eating disorder clinics at the University of Iowa in Iowa City in particular, were severely restricted in resource allocation, and amidst the financial burden of the state’s response to the COVID-19 pandemic (but realistically, this began unraveling in the previous two decades in particular), and then the concurrence of record high cases in the state for respiratory snctial virus (RSV), additional coronavirus variants, and seasonal viruses from the end of 2022 into 2023 further straining area hospitals in the state. It is of note that studies have linked instances of “long COVID” to impact on mental health (particularly chronic depression), further worsening the impact to Iowans’ mental health. According to patient advocacy group, Treatment Advocacy Center, Iowa’s capacity to address mental health services requiring such facilities provides approximately 2 beds per 100,000 people, contrary to the recommendation of 50 beds per the same population. According to the Iowa Department of Health and Human Services, only 64 beds are state supported, with 502 staffed private beds, with beds for children at 28 public and 97 privately staffed. As the facilities that remain able to provide services are largely in Iowa’s metropolitan centers in Western, Central, and Eastern Iowa, the population most affected are Iowa’s many rural citizens, almost a full third of the state’s 3.16 million person population as of the 2020 census, and in particular the indigent state wide due to the lack of publicly subsidized services, which according to the 2020 census, is 11% of the state, a group under the kind of economic and social pressure the reforms of the 1950’s and 1960’s had sought to cater to.

The Department of Justice has since determined that Iowa’s record on mental illness treatment availability has not had positive results, but reforms and, most importantly, funding has largely not been forthcoming for the public. There have been, however, efforts by the Governor’s office to form a children’s mental health board recommending ongoing screenings, however, consistent with the previous administration’s austerity measures, this process has been handed over to private, for-profit entities to execute and implement; a measure regarded by the state’s public health advocates as ill-conceived policy in light of a consistent reduction in resources available as well. There exists a wide gap, as a result, between the creation of this policy and its implementation with opinion decidedly mixed on how innovative or effective this can be at detecting and treating mental illness in the next generation of Iowans, while resources for adults continue to deteriorate as well. There have likewise been calls for reforms to Medicaid which limits the amount of spending on “brain disorders” in inpatient treatment contexts, which has been regarded as a failure and a massive de-institutionalization of those requiring treatment. There have been efforts at the county level, still under way, at replacement centers and facilities for those that might have closed, which is a laborious and time consuming, but ultimately the most materially impactful possible response. You see where this is going?

Another circumstance supporting this analysis is the public’s varied responses to when the state does, under the shadow of the influence over-corporatization of healthcare, during the pandemic: This latter theory is of relevance to my community: In Iowa, there were record highs in the nation for COVID-19 cases, with very low uptake of public health guidance for prevention and mitigation of the disease in public. Studies indicate that the Health Behavioral Model helps make sense of the data surrounding who complied and to what degree with guidance, as well as a willingness to receive vaccination, and for how many recommended dosages. Gender, for example, was the most reliable indicator, while race was an infrequent indicator of intent to comply, but where a strong perception was detectible, racial minorities were less likely to comply with guidance (again, a social byproduct of a bioethically questionable healthcare culture). By contrast, a study on willingness to receive the vaccine indicated a majority would intend to receive it, some would be likely to, with a minority (less than 20% of respondents) saying they would decline. The result concluded that the barrier to access (that the vaccine was being delivered free of cost) was the deciding factor for many, and a key driver of uptake of vaccination compared to other public health measures amidst a culture of skepticism about the illness more broadly. As a response to this skepticism, local medical conglomerates ensured deployment of testing and vaccination facilities and delivery of either to minimize friction in uptake in the absence of state government action (much of Iowa’s public health apparatus having been privatized as of 2019, which led to widespread mistrust of the state government in matters of public health, amid surging denials of care, leaving a void for corporatist response to rollout a program absent both public and state-private hybrid — ”neoliberal” as one study described it- healthcare response ). Postmodernism has been a highly debated and often criticized movement in various fields, including economics; Marxian economic reality is almost entirely, on a conceptual level, fixated on what is value and how it is derived and what is material and immaterial, the latter of which is almost entirely what postmodernism seeks to enshrine as equally valid and real to hold as a law of nature. Postmodernism’s rejection of objective truth and universal values has been seen by some as a threat to the validity of empirical research and scientific progress; some economists have used postmodernism as a framework for analyzing the impact of cultural and social factors on economic phenomena, particularly in the context of urban design and planning, and when viewed from the perspective of a materialist, this is the material fallout from the enforcement of postmodernist thought as the gatekeeper of to whom capital belongs and is accessible to, the question of alienation of labor aside for a moment for the purpose of demonstrating the harm done in material ways through social standards enforced on an immaterial basis.

Due to the neoliberal “hybridization” of Iowa’s public health apparatuses (basically full privatization, with postmodern emphasis on influencing outcomes through policy within this changed system rather than remediating that its cause was unforced, and the austerity willful), mirroring broader trends in healthcare nation-wide, health outcomes are now subject to the fiscal solvency of private healthcare providers, with barriers to accessible care only lowered by corporate benevolence in cases where sliding-care cost is offered, for example. A system engineering bad outcomes, a terminal lack of care, is the chief byproduct of postmodern thought, of capitalism in this context. Apply all of this to the culture of psychiatric diagnosis; if terminal is a label applied at diagnosis time for a condition that is merely sustained, can be but is not necessarily with treatment fatal, the central factor becomes whether or not this is someone the capitalist system can regard as “of use” and the extreme response is to relieve their suffering (removing a perceived burden, as capitalism regards it), rather than institute a healthcare culture that treats this as a function of community health, and not preemptively sentencing someone with a treatable condition to a mindset of ineveitable short-term death. The pernicious effect of postmodernism and capitalism on the treatment of psychiatric conditions, especially eating disorders, cannot be overlooked. The current trend of consumer rationalization and its emphasis on individualism and choice has led to a mass illness mentality, where patients are reduced to mere consumers of health care services. This approach ignores the complex social, cultural, and psychological factors that contribute to mental health issues. Instead, it promotes a one-size-fits-all approach that tends to prioritize quick fixes over long-term solutions. This approach is particularly problematic in the case of terminal anorexia, where patients face extreme physical and emotional challenges that require a more individualized and holistic approach to treatment.

Foucault emphasized the importance of understanding power dynamics in medical and psychiatric treatment, and argued that traditional approaches to diagnosis and treatment often reinforce oppressive systems rather than empowering patients, arguing that to abandon the dualism between the body and the soul was required to treat a whole patient, not an individual but patients as a class, taken on an individual basis: This means that we must go beyond traditional psychiatric diagnosis, acknowledging the influence of postmodern thought on medical treatment, and focus on the patient’s unique experiences, beliefs, and values as one vector in engineering better community health outcomes, addressing the root causes of the illness (a social concern, not a personal terminal illness inherently the sufferer’s to carry alone) and promote long-term recovery even for the sustained relapsing individual. Instead, we have a culture that commoditizes care, but as Foucault wrote, uses medical expertise as a way to divest public interest in deference to experts who represent capital, and not necessarily public health, interests.

At its core, the social problem most driving the exacerbation of these poor outcomes is poverty, and often forced poverty under western neoliberal capitalist policy. Per Foucault, “From being the object of a religious experience and sanctified, poverty became the object of a moral conception that condemned” — Foucault is referring to the changing perception of poverty in Western societies over time. He notes that in the past, poverty was often seen as a spiritual state that could bring one closer to God. However, as Western societies became more secular, poverty became increasingly viewed as a moral failing or a personal flaw. This shift in perception led to the stigmatization and condemnation of those who were poor, rather than their glorification or sanctification. Foucault’s point is that the way we understand and talk about poverty is not fixed, but rather shaped by historical and cultural context. In the context of our discussion, labeling a condition like anorexia terminal, rather than sustained or potentially lethal over a long enough timeline _if left untreated_, is another vector through which the extremes response of burdening an individual with, for example, the decision to die (and in this case being told you will die), becomes a routine part of the discussion, effectively tying value to how sick or not someone is, irrespective of if the system itself is to blame for the extremity of the condition in the first place. Beyond the question of it being unnecessarily and inaccurately labeled as hopeless, it resolves the question without even attempting care; it’s not the patient giving up, it’s the system.

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