Abstract
George Engel’s biopsychosocial model has been read through Michel Foucault many times, and the readings converge: the model is said to extend the medical gaze into the psyche and the social, to medicalize ever more of life, and to govern patients through self-management. This article argues the reverse. Life has been comprehensively medicalized for centuries, and eighteenth-century medical police, French urban medicine, and English Poor Law medicine claimed far more of collective life, and far more coercively, than any clinician applying Engel’s model. Measured against that history, the biopsychosocial model reveals no hidden expansion of medical power; what it does is articulate, explicitly, a medicine whose authority is restricted by private property, individual rights, markets, and the separation of jurisdictions: a medicine that recognizes the relevance of nearly every dimension of life while claiming authority to transform almost none of them beyond the patient. Drawing on Foucault’s own account of the property limits of urban medicine and of liberalism as the internal limitation of government, on Engel’s 1977 and 1980 texts, on the Chadwick–Alison controversy, Virchow, Myanmar under military rule, and the social determinants of health, the article reads the biopsychosocial model as an ideology of medicine under liberal sovereignty. Living Value Theory distinguishes the always multimediated reality of health from the historically professed ontologies through which political orders authorize what medicine may recognize and what it may change.
I. Introduction: How Much of Life May Medicine Claim?
In 1977 the psychiatrist George Engel argued in Science that “the dominant model of disease today is biomedical, and it leaves no room within its framework for the social, psychological, and behavioral dimensions of illness” (Engel 1977). A medical model adequate to the task, he wrote, must take into account “the patient, the social context in which he lives, and the complementary system devised by society to deal with the disruptive effects of illness, that is, the physician role and the health care system” (Engel 1977). He called it the biopsychosocial model, and within two decades it had become the official self-description of medical education, general practice, psychiatry, pain medicine, and rehabilitation across much of the world.
At first sight this looks like a conceptual revolution: medicine ceases to concern itself only with biological abnormality and turns to patients’ wider lives. A puzzle follows at once. What did this widening actually authorize? Did recognizing the importance of unemployment give medicine jurisdiction over labour markets? Did recognizing the effects of housing give physicians authority over housing policy? Did recognizing the consequences of deprivation allow medicine to reorganize the economy that produced it? It did none of these things. The remarkable feature of the biopsychosocial model is that it recognizes the importance of all these circumstances while leaving the distribution of authority over them intact.
The question of this article is why one of the most influential expansions of modern medical thinking took the form of adding psychological and social dimensions to biomedical knowledge, and not of expanding medicine’s jurisdiction over the conditions of life. Engel’s sincerity is not in doubt, and his intentions are beside the point; the question concerns why this particular articulation of medical comprehensiveness became so influential and so institutionally workable.
The answer proposed here departs fundamentally from the way Foucault has usually been brought to bear on the model. Foucauldian scholarship on the biopsychosocial model, and on modern medicine generally, sets out to reveal what medicine actually does beneath what it claims to do, and what it reveals is medicalization: the extension of medical power into new realms of life. This article starts from a different premise. Medical intervention into life has always been there, and life has been massively medicalized for centuries. Eighteenth-century medical police regulated marriage, childbirth, food, schools, and housing; urban medicine demolished houses and removed cemeteries; English medicine compelled the poor to be vaccinated and inspected. Against that history, the biopsychosocial model represents something else: the explicit articulation of a biomedical model whose authority is restricted by private property, individual rights, markets, and the separation of governmental jurisdictions. Its political significance lies in what it openly renounces as much as in what it claims. The model permits medicine to enlarge its explanatory field without enlarging its sovereign power. That is the article’s central paradox.
The argument requires one distinction from the outset. For Living Value Theory, health and healing are always irreducibly multimediated, occurring through multisensorial embodiment, multispecies being-with, multiversal dwelling, multimateriality, and multisymbolization at once. Every medical practice, including an avowedly reductionist one, operates within all five. What varies historically is professed medical ontology: what a medical model says health consists of, what it claims as its object, and where it locates the limits of its legitimate action. The article concerns this professed ontology and its political constitution, and it proceeds through the Foucauldian literature, Foucault’s own texts, the Enlightenment division of nature and culture, a close reading of Engel, and comparisons with medical police, Chadwick, Virchow, Myanmar, and the social determinants of health.
II. Against Revelation: The Usual Foucauldian Reading
A. Medicalization as the expansion of medical power
The sociology of medicine discovered medicalization in the 1970s. Irving Zola argued that medicine was becoming a major institution of social control, displacing religion and law, and that more and more of everyday life was being brought under medical jurisdiction (Zola 1972). Ivan Illich diagnosed a social iatrogenesis in which the medicalization of life made people dependent on professional care and disabled their own capacities to cope with pain, sickness, and death (Illich 1976). Peter Conrad traced the conversion of behaviours and conditions, from hyperactivity to menopause, into medical problems (Conrad 2007). These accounts share a narrative structure: a domain of life once outside medicine is progressively absorbed into it.
Foucauldian scholarship gave this narrative a theory of power. David Armstrong described the rise of a surveillance medicine in the twentieth century that problematized the normal, dissolved the boundary between health and illness, and spread the medical gaze from the hospital body into the community and the population through risk factors, screening, and health promotion (Armstrong 1995). Nikolas Rose showed how the psy disciplines made subjectivity itself governable, and how advanced liberal government came to operate through the freedom and self-regulation of autonomous individuals (Rose 1996, 1999). Applied to the biopsychosocial model, these frameworks yield a familiar reading. By requiring clinicians to assess the psychological and the social, the model is said to extend the medical gaze into emotions, family relations, coping styles, and ways of life; to discipline patients by locating the causes of their failure to recover in maladaptive cognitions or poor compliance; to supply governments and insurers with cheap psychological interventions that return citizens to productive work; and to produce responsibilized patients who manage their own conditions. The holistic ideal of the model, on this reading, conceals an intensification of power.
B. Why this reading misdescribes the model
The revelation model rests on an assumption that the history of medicine does not support: that there was once a baseline of life outside medicine, which medicine has since colonized. Measured against the eighteenth and nineteenth centuries, the twentieth-century clinic looks less like a conqueror of new realms than like a medicine that has withdrawn from most of the realms it once claimed. Johann Peter Frank’s system of medical police extended medical administration to procreation, pregnancy, infancy, schools, diet, clothing, housing, and burial (Frank 1779). French urban medicine took the plague quarantine as its model, analysed the city’s zones of danger, and removed cemeteries and slaughterhouses to the periphery (Foucault 2000, 146–48). English Poor Law medicine subjected the poor to medical control as a condition of relief, and from 1875 the health offices compelled vaccination, made the notification of dangerous diseases mandatory, and destroyed unhealthy dwellings (153–54). Life was medicalized then, far more comprehensively and coercively than in any consultation conducted along biopsychosocial lines.
Seen against this history, the biopsychosocial model shows a distinctive combination: an expansion of medical recognition and a contraction of medical jurisdiction. The clinician is to recognize family, work, housing, income, and culture as consequential for illness, and to act on the patient. What needs explaining is the shape of this restraint, and far from being a hidden truth that critique must uncover, it is stated on the surface of the model, which sets out the domains of life that medicine must know and locates the physician’s action at the level of the person. The biopsychosocial model is an ideology in the precise sense of an explicit articulation of medicine’s place in a political order, and it can be read directly.
The revelation model also inherits, without noticing, the political order it ought to explain. To describe the assessment of a patient’s family or housing as an intrusion of medicine into private life presupposes a private sphere that is naturally outside medicine. That sphere is a historical achievement of liberal sovereignty. It was secured by the same doctrines of property, privacy, and individual right that, as Foucault noticed, kept urban medicine at the threshold of the house. The medicalization critique measures medicine against a boundary that liberalism drew, and then reads every crossing of that boundary as an expansion of power. The biopsychosocial model shares the same premise from the other side: it crosses the boundary in knowledge and respects it in action. Both treat the liberal division between medical and private life as the baseline from which deviations are to be measured. Neither asks how that baseline constitutes what medicine can profess health to be.
A further consequence follows. A theory that looks only for the expansion of medical power cannot see its contraction. Political orders can refuse medical recognition as readily as they impose it, and the absence of a diagnosis can be as politically produced as its proliferation. The case of depression under Myanmar’s military rule, discussed below, shows a regime suppressing a psychiatric category because it pointed to the regime’s own responsibility. The revelation model has no place for such a case, because it assumes that power always tends towards more medicine.
The difference from the existing scholarship is therefore one of question as well as conclusion. The Foucauldian critique asks what new domain medicine has penetrated. This article asks what medicine has accepted it may not touch, and why the most influential modern statement of medical comprehensiveness took a form that leaves property, wages, tenure, and employment outside medical authority. Rose’s analysis of advanced liberal government comes closest, since it recognizes that liberal power works through autonomy and at a distance. But it treats these limits as a more refined technique for extending government into the self. The argument here treats them as limits that shape what medicine can profess health to be.
III. Foucault: Biopower, Sovereignty, and the Political Limits of Medicine
A. From sovereign power to biopower
Foucault’s own texts support this reorientation better than the literature that applies them. In The History of Sexuality he described how the sovereign “right to take life or let live” was overlaid from the seventeenth century by a power “that exerts a positive influence on life, that endeavors to administer, optimize, and multiply it, subjecting it to precise controls and comprehensive regulations” (Foucault 1978, 136–37). This power developed around two poles, “an anatomo-politics of the human body” and “a bio-politics of the population” (139), and in Society Must Be Defended he summarized the new right as the power “to make live and to let die” (Foucault 2003, 241). Medicine became central to this history because it allowed political authorities to act on birth, mortality, reproduction, epidemics, and the health of populations. Biopower leaves one question open: how far may medicine extend its claims about what must be changed for life to be sustained? Regimes that share the aim of fostering life can place very different limits on the means through which it is pursued.
B. The property limits of urban medicine
In his 1974 lecture “The Birth of Social Medicine”, Foucault distinguished three forms of social medicine and connected each to a political structure. German state medicine, built in small and unstable states, standardized the medical profession, appointed medical officers for districts of six to ten thousand inhabitants, and made the doctor “a health administrator” (Foucault 2000, 140–41). English labour-force medicine tied medical assistance to the control of the poor and established “an officially sanctioned sanitary cordon between the rich and the poor” (153). French urban medicine is the decisive case for this article. It was, Foucault wrote, “not really a medicine of man, the body, and the organism but a medicine of things”, of air, water, decompositions, and fermentations; “a medicine of the living conditions of the existential milieu” (150). Its central concept, salubrity, “did not mean the same thing as health; rather, it referred to the state of the environment and those factors of it which made the improvement of health possible” (150). And its reach was bounded. The state claimed the subsoil but not the surface, and public spaces, cemeteries, and slaughterhouses but not private dwellings: “The problem of private property, a sacred principle, kept this medicine from being endowed with a strong authority” (149–51).
Here Foucault identified, without developing it, the historical precursor of the biopsychosocial paradox. A medicine could understand health to depend on the whole living milieu while its authority stopped at the threshold of the private house. The distinction between salubrity and health is itself a boundary of jurisdiction drawn inside medical ontology.
C. Liberalism as the internal limitation of government
The Birth of Biopolitics makes the point general. Foucault presented liberalism as a governmental rationality organized around the question of its own limits: the problem of liberal government is less how to govern effectively than how to avoid governing too much, and markets, private interests, rights, and liberties become limits that government must take into account from within its own reasoning (Foucault 2008, 10–22). Liberalism, in this account, is an art of government that constantly asks where government ought to stop. If medicine increasingly claims to know the conditions of healthy life while liberal government develops principles limiting legitimate intervention in economic and private affairs, a tension opens within biopolitics itself. Medicine’s explanatory reach can grow far beyond its authorized transformative reach.
D. From biopower to the political purview of medicine
Foucault explained how medical knowledge became intertwined with governmental rationalities. He did not compare the self-definitions of medical models according to the extent of intervention that a political order permits. Three questions remain open. What does a political order permit medicine to recognize as a medical concern? What does it permit medicine to claim as a legitimate object of intervention? And how do medical models stabilize or challenge the difference between the two? Biopower concerns the political government of life. The political purview of medicine concerns the historically authorized domain within which medicine may explain, recommend, regulate, and intervene. The second cannot be inferred from the first, and the biopsychosocial model is an unusually revealing expression of their difference.
IV. The Enlightenment SWIPE and Liberal Sovereignty
A. The ideological division of nature and culture
Living Value Theory calls a SWIPE a split of worlds paired with incommensurable epistemologies: the division of a single living world into domains represented as if each required its own form of knowledge. The most consequential SWIPE of modernity separated nature from culture. Nature became the object of the natural sciences; society, meaning, and politics were assigned to others. Medicine came to articulate its scientific authority through the study of biological processes and interventions that could be evidenced within the natural sciences. The division never matched living reality, in which a fever, a household, a landlord, and a season belong to one coordination. It organized knowledge about that reality, and through knowledge it organized institutions.
B. Transactive dualism and liberal sovereignty
Liberal political orders organize legitimate action through protected but interacting spheres of authority. Property owners exercise power over assets; individuals hold rights over bodily integrity, privacy, association, and movement; employers direct work within legal limits; markets coordinate much of economic life; governments act through legally defined powers. Underlying these arrangements is what Ecks has called transactive dualism, the assumption that the world consists of discrete actors and discrete objects linked by readable transactions (Ecks 2022). Medicine holds recognized authority over certain forms of bodily intervention and professional knowledge, but it cannot convert medical explanation into sovereign authority over the conditions that explanation implicates. Liberal sovereignty is no weaker for this, since it is constituted through legally and politically mediated limits that determine the legitimate distribution of power, and medical authority is one such distributed authority.
C. Two divisions that reinforce each other
The nature/culture SWIPE gives ideological legitimacy to the distinction between bodily processes and social circumstances. The liberal distribution of authority gives that distinction a practical setting. A doctor treats an infection; a housing authority regulates a dwelling; an employer sets the conditions of work; a legislature changes employment law; a court decides whether a right has been infringed. The two divisions are not identical, but each makes the other seem natural. The result is a medical model that may explain illness by conditions over which its practitioners have little independent authority, and medicine can become ever more comprehensive in its claims to knowledge while remaining bounded in its claims to intervention.
D. The historical claim stated carefully
Private property and individual rights are not untouchable in liberal states. Public health law, taxation, compulsory purchase, housing regulation, and emergency powers all restrict them. The point concerns their status as foundational rights that intervention must justify crossing. When a liberal state compels vaccination, orders drainage works, regulates landlords, or restricts movement during an epidemic, it does so through specific legal powers and contested public justifications. Medical claims do not by themselves override property and rights, as they would under an idealized sovereign command. That tension, not an absolute prohibition, is what makes the biopsychosocial model interesting.
V. The Biopsychosocial Model as an Ideology of Liberal Medicine
Ideology is used here in a specific sense, which has nothing to do with false consciousness or a veil that critique must lift to expose a hidden reality: it means an explicit, institutionally stabilized articulation of what a practice is and may do. In the terms of Living Value Theory, a medical model of this kind is a stabilization at the fourth level of recursivity: a classification that has become institutional, taught in curricula, written into guidelines, and used to define competence. Such a model can be read directly, because its claims about the scope of medicine are part of what it says.
A. Engel’s challenge to biomedicine
Engel’s target was a biomedical model that, in his words, had acquired the status of a dogma, and that treated disease as deviation from measurable biological norms (Engel 1977). He wrote against two positions in the psychiatry of the 1970s: those who would exclude “problems in living” from medicine and leave them to other professions, and those who would reduce psychiatric disorder to brain disease. Drawing on general systems theory, he proposed a model for the whole of medicine, not for psychiatry alone. He insisted that “the boundaries between health and disease, between well and sick, are far from clear and never will be clear, for they are diffused by cultural, social, and psychological considerations” (Engel 1977), and he asked physicians to take responsibility for evaluating the whole range of problems patients bring. Engel was challenging a reductionist orthodoxy, and the challenge mattered.
The context of the challenge is revealing. Engel feared that if psychiatry narrowed itself to brain disease, the problems of living that patients brought to doctors would pass to psychologists, social workers, and counsellors, and medicine would lose them. Andrew Abbott has shown that professions define themselves through claims to jurisdiction over particular problems, and that they compete for those problems with neighbouring professions (Abbott 1988). Engel’s model was in part a jurisdictional claim of this kind, an argument that medicine, and psychiatry within it, should retain responsibility for the whole patient against rival professions. Professional jurisdiction in Abbott’s sense must, however, be distinguished from political jurisdiction over the conditions of life. The biopsychosocial model expanded medicine’s professional claim within the clinic, relative to other professions, while leaving untouched the political purview of medicine relative to property owners, employers, landlords, and legislatures. It enlarged the problems medicine could claim to understand and manage, and it did so entirely on the side of the patient.
B. The three domains
The interpretive question is why the challenge took the form of a model integrating three domains. The biological, the psychological, and the social enter the model as recognizable categories whose relevance must be brought into relation. Engel understood them as interacting and drew on systems theory precisely to resist reduction. From the standpoint of Living Value Theory, the three domains nonetheless remain inherited classifications. The biological is associated with physiology, pathology, and biomedical intervention; the psychological with experience, cognition, feeling, and individual behaviour; the social with relationships, institutions, roles, and socioeconomic circumstances. The model asks the clinician to consider all three, and so it repairs a historical division without questioning the categories that division produced. It assembles domains of an already divided life instead of starting from the coordination through which life continuously happens. This is a critique of the model’s architecture, and it does not attribute to Engel a denial of interaction.
C. A hierarchy of systems and a single point of action
Engel’s 1980 paper on the clinical application of the model makes the political structure visible. It presents a hierarchy of natural systems running from subatomic particles, atoms, molecules, cells, tissues, organs, and the nervous system through the person, the two-person relationship, the family, the community, culture and subculture, and society and nation, up to the biosphere (Engel 1980). Engel illustrated it with the case of a man in his fifties brought to hospital with a heart attack, showing how his work, his family, his reluctance to seek care, and a mishandled encounter in the emergency department all entered the course of his illness.
The hierarchy recognizes everything from molecules to the biosphere as relevant to illness. The physician’s action, however, is located at one level: the person, approached through the relationship between doctor and patient. The levels above the family, community, culture, society and nation, biosphere, are known and named, and they are acted on by others. Engel was explicit that the physician must understand the higher levels in order to understand the patient, and that the patient’s illness could originate anywhere in the hierarchy. He did not propose that the physician should intervene in the community, the culture, or the nation. Information travels up and down the diagram; authority does not. The diagram depicts, with unusual clarity, a medicine whose ontology extends across all of nature and society and whose jurisdiction occupies a single node. That is the biopsychosocial model as ideology: a map of everything medicine must understand, with a mark at the point where it may act.
D. Comprehensive recognition, limited jurisdiction
Consider a patient presenting with depression. The physician may identify contributions from biological processes, bereavement, family conflict, insecure employment, damp housing, and debt. The biopsychosocial model encourages this recognition. What can medicine then legitimately do? It can diagnose, prescribe, provide or refer for psychotherapy, counsel, document, advise, and advocate. It does not thereby acquire authority to raise the patient’s wages, alter a landlord’s rights of ownership, restructure an employer’s business, allocate a house, or rewrite social security law. Those transformations require other powers and other forms of political authorization. Biopsychosocial recognition is not biopsychosocial jurisdiction, and the breadth of the model’s explanatory claims is institutionally compatible with a much narrower scope of intervention. The model lets medicine represent itself as comprehensive without claiming sovereignty over the circumstances it identifies, and this makes it a particularly suitable medical ideology within liberal political arrangements. Doctors campaign for reforms and medical knowledge shapes legislation, but the model does not itself dissolve the division between recognizing a problem and acquiring the power to transform its conditions.
E. When recognition substitutes for transformation
One ideological effect of the model is to make acknowledgement appear equivalent to comprehensiveness. A clinician may record financial insecurity, employment, relationships, and housing in an assessment and then have no institutional response beyond advice, referral, or helping the patient adapt. The social dimension enters the medical formulation without becoming an object of medical intervention, and medicine continues to locate its principal interventions in the patient: medication, psychotherapy, behavioural change, symptom management, coping. Social prescribing in the English National Health Service shows the arrangement in its contemporary form. A general practitioner who recognizes that distress is bound up with isolation, debt, or housing refers the patient to a link worker, who connects them with a walking group, a debt advice service, or a community garden. The recognition is medical; the remedy is a referral across the boundary of medical jurisdiction into voluntary and municipal services whose capacity medicine does not control. This is a recurrent institutional tendency, and not an inevitable effect of every application of the model.
F. Professional responsibility and political sovereignty
A serious objection must be met. Engel explicitly wanted physicians to take greater responsibility for patients’ broader problems, and critics have read his proposal as enlarging medicine’s professional jurisdiction. The point strengthens the argument. Engel’s programme contains an expansionary impulse: it asks medicine to know and consider more of life. Taking responsibility for evaluating a problem is different from gaining authority to transform the institutions that produce it. The model therefore occupies an unstable position between professional expansion and political self-limitation. It is a theory through which medicine can press against the boundaries of its jurisdiction without overcoming them, which is also why the Foucauldian reading can find in it an expansion of power and miss the limits that give the expansion its form.
G. Why the model is not a multimediational ontology
The model’s category of the social is especially revealing. It gathers relationships, social support, class, work, and housing, but these neither constitute an adequate account of multispecies being-with nor exhaust multimateriality, multiversal dwelling, multisensorial embodiment, or multisymbolization. A person does not first possess a biological state on which a social condition subsequently acts; illness and healing occur through ongoing living coordination. Existing criticisms of the model have pointed to its vagueness, its eclecticism, and its lack of a specified mechanism linking the three domains (Ghaemi 2009; Benning 2015). The criticism here is different. The model’s inadequate ontology is historically and politically intelligible, because its categories match a world already divided into separate domains of scientific and political responsibility.
H. A historical compromise
The biopsychosocial model is a challenge to biomedical reductionism and a historically specific compromise with the political organization of medicine. It expands what medicine may legitimately recognize without specifying any corresponding expansion of what medicine may govern. Its comprehensiveness is politically structured, and that structure is stated openly in its categories and its diagram. It is the clearest articulation available of medicine under liberal sovereignty.
VI. Historical Contrasts: Sovereignty and the Permissible Scope of Medicine
A. Medical police: encompassing intervention
Frank’s System einer vollständigen medicinischen Polizey, whose first volume appeared in 1779, placed procreation, childcare, schooling, food, housing, and the cleanliness of towns within the responsibilities of medical administration (Frank 1779). George Rosen showed how this conception grew out of cameralism, in which a large, healthy, and productive population was the foundation of the prince’s revenue and military strength (Rosen 1953). Eighteenth-century monarchies possessed no adequate ontology of health, and they implemented little of what these programmes proposed. The point is that the remit of medicine could be framed through the comprehensive responsibilities of territorial government. Where Frank placed the broad conditions of life within the normative responsibilities of medical administration, Engel represents those conditions as dimensions that medicine must acknowledge within clinical understanding. One ideology tends towards encompassing intervention, the other towards encompassing recognition. That is the central comparison, and it is not a contrast between authoritarianism and democracy. Foucault himself observed that Chadwick drew on German methods in formulating his plans (Foucault 2000, 153), and Patrick Carroll has shown that medical police was neither confined to continental absolutism nor absent from British public health, whose reformers knew and drew on its terms and practices (Carroll 2002). The contrast is between doctrines of medical sovereignty, not sealed political civilizations.
B. Chadwick: defining disease by what government could change
Edwin Chadwick provides the strongest historical bridge to Engel. Before his sanitary report of 1842, physicians such as William Pulteney Alison in Edinburgh argued that epidemic fever followed destitution, and that its remedy lay in adequate relief and wages. Chadwick, architect of the New Poor Law, located the cause of fever in filth, decaying refuse, and foul air, and its remedy in drains, sewers, and piped water. Christopher Hamlin has shown how this turned public health away from poverty and wages, which would have implicated the Poor Law and the labour market, towards engineering works that a liberal state could undertake without redistribution (Hamlin 1998). Both explanations addressed real features of living conditions. The difference lay in their political implications. Sanitary reform did not avoid interfering with property: sewer construction, drainage, and housing regulation could be coercive. But it offered an account of disease compatible with a particular set of public powers, while accounts centred on deprivation remained contested. Here a medical model made certain conditions of life visible as medically consequential and at the same time defined which interventions properly followed. Chadwick organized causation around what established authority could change; Engel organized recognition around what medicine was authorized to do.
C. Virchow: when medicine refuses its limits
In 1848 the Prussian government sent Rudolf Virchow to investigate an epidemic of typhus in Upper Silesia. He traced it to poverty, hunger, ignorance, and political exclusion, and called for education, freedom, prosperity, self-government, the use of Polish in schools and administration, agricultural reform, and full and unlimited democracy (Virchow 1848; Taylor and Rieger 1985). Instead of accepting the available jurisdiction of medicine, Virchow demanded the transformation of political life, and wrote that medicine is a social science and politics nothing but medicine on a large scale. Both Virchow and Engel argued for expanding medicine beyond a narrow biomedical framework. Virchow drew from that expansion a demand on the state; Engel drew from it a responsibility of the clinician.
D. Synthesis
Medical police, sanitary reform, and Virchow represent three relations between medical explanation and political authority. In the first, government over the conditions of life could be represented as a medical responsibility. In the second, explanations of disease aligned themselves with institutionally acceptable interventions. In the third, medicine challenged the prevailing limits of political authority. A later case, the Mao-era campaigns against schistosomiasis, which joined treatment to the reshaping of irrigation and the collective organization of rural labour, shows that encompassing intervention could also be pursued through socialist mobilization, and that its lasting successes came more from subsidized treatment and trained local health workers than from command (Gross 2016). Against this variability the biopsychosocial model appears as one historically specific settlement among several.
VII. Myanmar: The Selective Expansion and Suppression of Medical Recognition
A. The Drug Elimination Museum
Myanmar shows how sharply the scope of medical recognition can vary even within a single political formation, and its importance lies there, not in any suggestion that authoritarian systems understand health more comprehensively. The Drug Elimination Museum in Yangon presents drug elimination as far more than the removal of substances from bodies. Its displays combine treatment and rehabilitation with pig farms for alternative income in Shan State, mushroom cultivation as a substitute crop, roads into the hills, industrial development, and the reintegration of growers and users into national life (Ecks 2025). These conditions are claimed as legitimate objects of comprehensive state intervention, where liberal medicine would acknowledge them as determinants and refer them elsewhere. The museum is evidence of official representation, not of what the programme achieved, and the military’s involvement in the narcotics economy invites the reading of it as propaganda. It is also evidence of state remediation, which must be distinguished from the jurisdiction of clinical medicine.
B. The suppression of depression
Within the same political order, psychiatric recognition moved the other way. The Ministry of Health’s report for 2014 to 2016 listed six people with depression per hundred thousand, and a study of three Yangon community clinics recorded about ten diagnoses of psychosis for every diagnosis of depression, although Yangon had trained psychiatrists and affordable antidepressants (Ecks 2025). Psychiatrists interviewed before 2020 explained the gap politically. Schizophrenia could be represented as biological and so politically safe, while depression, anxiety, and trauma pointed to the consequences of military rule: “Schizophrenia is not ‘their fault’, but trauma, anxiety and depression are.” A researcher who found depression among a fifth of four hundred medical staff was told that this was “not Myanmar result”, and his funding application was rejected. The museum itself joins the two movements, since it displays antidepressants among the “psychotropic drugs” from which the nation must be protected. These accounts are interview evidence from an urban, English-speaking group of clinicians, and they establish reported political constraints on diagnosis, not documented state instructions.
C. The comparative significance
The military state could represent the reorganization of livelihoods and territory as a legitimate response to drug production while treating certain psychiatric explanations as politically dangerous. That configuration differs from the one the biopsychosocial model expresses, and neither is more adequate to the multimediated reality of health. The museum’s expansive remedial claims may coexist with coercion, displacement, and failure; liberal protections against intrusive intervention may preserve vital possibilities for living even as they restrict medical authority. Ranking regimes by how much they intervene would miss the point, which is that sovereign authority conditions which connections medicine can officially recognize and which interventions can be justified, and that these boundaries are selective, drawn according to what particular diagnoses mean for the authority that draws them.
VIII. The Social Determinants of Health: A Universal Concern without Sovereignty
The World Health Organization’s Commission on Social Determinants of Health declared in 2008 that social injustice is killing people on a grand scale, and called for improving daily living conditions and tackling the inequitable distribution of power, money, and resources (CSDH 2008). This literature is neither politically indifferent nor committed merely to individual treatment, and in several respects it is far more ambitious than a clinical reading of Engel. Yet the terminology is revealing. Housing, poverty, employment, education, and social protection become determinants of health. The category gives them explanatory significance while preserving a conceptual difference between health and the political-economic conditions said to influence it, and it does not make those conditions objects of medical sovereignty. The Commission can demand reform, but implementing it requires governments, legislatures, employers, municipalities, and other institutions. The liberal response to this gap is characteristic. Health in All Policies, adopted under the Finnish presidency of the European Union in 2006 and promoted by the World Health Organization in its Helsinki Statement of 2013, asks every sector of government to consider the health consequences of its decisions (WHO 2014). Recognition of health is thereby distributed across all ministries, while authority over housing, transport, labour, and finance remains with the ministries that already held it. The biopsychosocial model expands clinical recognition; the social-determinants framework expands public health recognition; neither settles who has legitimate authority to reorganize the circumstances recognized. From the perspective of Living Value Theory, these circumstances participate in the constitution of health instead of surrounding it from outside. The division between health and its determinants is reinforced by the distribution of institutional authority, and liberal biopolitics can therefore acknowledge that virtually everything affects health without assigning to medicine the authority to change everything.
IX. Living Value Theory: What Biopower and Medical Ideologies Cannot Explain
Living Value Theory holds that life consists in recursive coordination across five irreducible mediations, which are constitutive of living and not dimensions added to an independently existing biological individual. Medical practice never operates within a purely biological domain, even when its official model says it does. The SWIPE is ideological, and it does not fragment living reality. Medical ideologies nevertheless make real differences. They determine what can be represented as an illness, what counts as a plausible explanation, which claims become institutionally authoritative, and which interventions can be justified. Political sovereignty shapes these possibilities without determining them completely, and practitioners can know more than their models profess. In Ecks’s fieldwork in Kolkata, general practitioners rooted in their patients’ neighbourhoods recognized patients’ everyday circumstances more readily than psychiatrists working with formal diagnostic criteria (Ecks 2008). One doctor at the edge of a slum declined to prescribe antidepressants to a severely depressed woman who was her family’s only provider, because the cost and the drowsiness would, as he put it, bring down the house (Ecks 2022). Such judgements draw on the mesocosm itself, and no medical ideology exhausts them.
The limits of liberal medicine also protect something. Foucault noted that the dissident religious groups of nineteenth-century England resisted compulsory medicine by asserting “the right to life, the right to get sick, to care for oneself and to die in the manner one wished” (Foucault 2000, 155). The right to refuse treatment, the privacy of the household, and the patient’s control over what a doctor may know are restrictions on medical authority, and they are also protections of the recursive coordination on which healing depends: the trust between patient and healer, the self-repair of bodies, the adjustments of households. Healing involves nonrecursive, selfrecursive, and interrecursive counterparts at once. Commands, plans, and targets can reach its nonrecursive aspects, a drain dug, a road paved, a drug dispensed; its recursive aspects answer back to how they are engaged and cannot be ordered into existence. A medicine with unlimited sovereignty would therefore be no guarantee of more healing, and the liberal restraint that the biopsychosocial model articulates is, in this respect, more than a defect.
Biopower identifies the political government of life. Living Value Theory distinguishes that government from the living processes it seeks to know and influence, and it reframes the comparative question: which aspects of the multimediated constitution of health does a political order permit medicine to recognize, and which does it authorize medicine to transform? This question does not assume that expansive governmental power produces effective healing, and it allows the ideological limits of a medical model to be identified while acknowledging that its practitioners may accomplish real healing.
X. Conclusion: The Sovereign Limits of Biopsychosocial Medicine
Engel’s model is conventionally celebrated as an enlargement of medicine’s understanding of illness, and conventionally criticized, in the Foucauldian literature, as an enlargement of medical power. This article accepts the first and rejects the second. Medicine has intervened in life for centuries, and the medical police, urban medicine, and Poor Law medicine of the eighteenth and nineteenth centuries claimed more of collective life than any biopsychosocial clinician. What is historically distinctive about the model is the explicit form it gives to medicine’s restraint. By recognizing biological, psychological, and social dimensions without enlarging medicine’s authority over the institutions they implicate, it articulates a biomedicine bounded by private property, individual rights, markets, and the separation of jurisdictions.
That articulation is not universal. Medical police, Chadwick’s sanitary reform, Virchow’s social medicine, and Myanmar each related medical explanation differently to the politically legitimate scope of intervention. Foucault’s account of biopower provides the framework for understanding medicine’s entanglement with power, and his own observation that private property kept French urban medicine from strong authority anticipates the paradox examined here. Health is always multimediated. The argument can be tested further by comparing curricula, clinical guidelines, and the definitions of competence through which different health systems teach doctors what they may recognize and what they may change. What varies politically is the authority medicine claims to recognize and to transform the mediations through which health occurs, and the biopsychosocial model is the ideology of a medicine that has learned to recognize nearly everything and to change very little beyond the patient.
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