The essence, part I: my dissertation as word cloud


Dissertation now on Google Books

My doctoral dissertation (Subject of Innovation, or: how to redevelop ‘the patient’ with technology) is now on Google Books. You can browse through parts of the dissertation by clicking the image.

A full PDF copy can be downloaded from the Leiden University Library

December 20, 10 AM: PhD defense

Academy building

(voor Nederlands, zie hieronder)

The defence of my PhD dissertation (Subject of innovation, or: how to redevelop “the patient” with technology) has been scheduled for December 20, 10.00 AM. The defence will take place at the Academy building (picture to the left). As to provide a bit more information on the contents of the dissertation, I printed an abstract below (in both English and Dutch). Parts of the thesis were published in journals, or conference proceedings. These can be found in the publications section. Slides of a presentation that I held on the dissertation once can be found here.


People are shaped in many ways: as subject of scientific inquiry, as part of a political category or in relations with others. Alternatively, they shape themselves. Michel Foucault examined such ways of ‘subjectivation’: the manner in which the human ‘subject’ is formed. He is most famous for his work on the role of surveillance in society. Contemporary critics argue that the surveillance he describes was only possible in the industrial era, in which people were often confined to closed spaces: schools, factories or hospitals. With the coming of the information era, however, the surveillance model is said to be defunct. People are much more distributed, to name just one distinction.

One way of assessing the value of Foucault’s work for present-day questions is to examine how ‘subjectivation’ relates to technology. His work on neoliberalism provides a starting-point. We do need to look further though, for example at Bruno Latour’s work. He claims that technologies are to people what ‘plug-ins’ are to the internet. The web is personalised by installing different plug-ins, add-ons or apps. Similarly, our subjectivity is shape by the technologies with which we engage. Question is how this turns out in practice.

Michel Foucault, 1926-1984

In order to take such a practical angle at these philosophical questions, this study examines the case of healthcare innovation. It articulates how patients are shaped in relation to technology. Technology is placed in a particular context when it is drawn into a discussion about innovation. The Dutch Electronic Health Record and the Personal Healthcare Budget are political designs that aim to foster innovation. Both policies started mid-1990s and were nearly abolished in 2011. What happened over the course of these one and a half decades?

Apart from these two policies, the study also covers other innovation-related developments in Dutch healthcare: the so-called Diagnosis Treatment Combinations, functional description techniques for health insurances, the Quality-Adjusted Life Years calculation and medical chat rooms.

It ends by examining the possibilities of democratising healthcare innovation, by investigating the example of ‘Living Labs’. These are local or regional platforms in which people are in some way involved in innovation processes. Just like for the different policies, the crucial question is: which role is attributed to the patient?

Nederlandse versie

De verdediging van mijn proefschrift (Subject of innovation, or: how to redevelop “the patient” with technology) staat op de agenda voor 20 december 20 om 10.00 ‘s ochtends. Het zal plaatsvinden in het Academie gebouw (zie het plaatje links boven). Om een beetje meer informatie te geven over de inhoud van het proefschrift heb ik hieronder een hele korte samenvatting gemaakt, met mogelijkheid om door te klikken naar Wikipedia. Delen van het proefschrift zijn gepubliceerd in wetenschappelijke tijdschriften of proceedings van conferenties. Deze zijn te vinden in de publications sectie. De slides van een presentatie die ik ooit over het proefschrift heb gehouden zijn hier te vinden.


Mensen worden op verschillende manieren gevormd: als onderwerp van wetenschappelijk onderzoek, als deel van een politieke categorie of in relaties met anderen. Het alternatief is dat ze zichzelf vormgeven. Michel Foucault onderzocht dit soort vormen van ‘subjectivering’: de manieren waarop het menselijk ‘subject’ wordt gevormd. Hij is het bekendst voor zijn werk over de rol van toezicht in de samenleving. Hedendaagse critici stellen dat het toezicht dat hij beschrijft alleen mogelijk was in het industriële tijdperk, toen mensen nog vaak werden samengebracht in afgesloten ruimtes: scholen, fabrieken of ziekenhuizen. Met de komst van de informatiemaatschappij zou het toezichtmodel geen stand meer houden. Mensen zijn nu meer verspreid, om maar iets te noemen.

Bruno Latour, 1947-present

Een manier om de waarde van Foucault’s werk voor hedendaagse vraagstukken te bepalen is door te onderzoeken hoe ‘subjectivering’ verband houdt met technologie. Zijn werk over het neoliberalisme vormt hiervoor een aanknopingspunt. Toch moeten we verder kijken, bijvoorbeeld naar het werk van Bruno Latour. Deze claimt dat technologieën voor mensen zijn wat ‘plug-ins’ voor het internet zijn. Het web wordt gepersonaliseerd door verschillende plug-ins, add-ons of apps te installeren. Op vergelijkbare wijze wordt onze subjectiviteit gevormd door de technologieën waarmee we omgaan. Het is de vraag hoe dit in de praktijk uitpakt.

Om op een dergelijke praktische manier naar dit soort filosofische vragen te kijken wordt in dit onderzoek zorginnovatie als voorbeeld genomen. Zo wordt zichtbaar hoe patiënten worden gevormd in relatie tot technologie. Technologie wordt in een specifieke context geplaatst als het in een discussie over innovatie wordt genoemd. Het Nederlandse Elektronische Patiëntendossier en het Persoonsgebonden Budget zijn politieke ontwerpen die worden geacht innovatie te bevorderen. Beide beleidsontwikkelingen begonnen rond de helft van de jaren ’90 en werden nagenoeg stopgezet in 2011. Wat gebeurde er in de loop van dit anderhalf decennium?

Behalve naar deze twee beleidsterreinen gaat het onderzoek nog in op andere innovatiegerelateerde ontwikkelingen in de Nederlandse zorg: de Diagnose Behandel Combinaties, de functiegerichte omschrijving van zorgverzekeringen, de zogenaamde Quality-Adjusted Life Years berekening en de medische chat rooms.

Het onderzoek eindigt met het bestuderen van de mogelijkheden om zorginnovatie te ‘democratiseren’, door te kijken naar het voorbeeld van ‘Living Labs’. Dit zijn lokale of regionale platforms waarin mensen op de één of andere manier worden betrokken bij innovatieprocessen. Net als voor de genoemde beleidsterreinen geldt ook hier dat de cruciale vraag is: welke rol wordt aan de patiënt toegekend?

New publication: Constituting the “good patient”

Our paper (with Frans Birrer), Constituting the “good patient“, was published in the proceedings of the 2010 conference of the International Society for the Study of Argumentation (ISSA). Also here, the question is how innovation is related to the subjectivity of the patient, as Michel Foucault would put. The Dutch Personal Healthcare Budget – receiving “cash-for-care” instead of a treatment “in kind” – is presented as a scheme that ought to enhance innovation. By getting patients to control the budget, they are expected to become rational consumers who only spend their money on innovative care providers. This way of reasoning is often criticised. However, the discussion is built up around a large number of arguments, which make up a cluster that is hard to penetrate. Effectively, criticism is often evaded in these types of debates, as we show in the paper. The question is how this relates to political accountability. With respect to the patient, we may wonder if (s)he wil really turn out to be a “good patient”:

‘Is (s)he indeed a cash-supported, rational sovereign, who constantly shuffles elations with care givers and is putting pressure to break rigid healthcare institutions? On the basis of the problems that participants in the policy discussion raised, another image of the patient-subject appears. It could also be an overburdened individual, constantly involved in unequal power relations, suspect in the eyes of government and society, and, therefore, increasingly constrained. This points at an entirely different type of subject, a “problematised subject”, so to say’.

Lecture on the “Subject of innovation”

On November 30, I hold a lecture  at the Insitute of Health Policy & Management at Rotterdam University. This is the first time I provide a somewhat comprehensive overview of my PhD research. Below is a short abstract of the lecture topic.

Innovation in healthcare does not leave the patient untouched. The healthcare reforms of the past decades have partly aimed at giving shape to a new type of patient. For the Netherlands, this is probably best summarised by the Public Health Council’s term “good patientship”. Technology and innovation play an important role in this development. First, it is important to consider which measurements are devised to assess the impact of innovation. It is expected to make both patients and care providers more productive. Second, there are a number of policies to stimulate innovation. I restrict myself to attempts – so-far unsuccessful – to roll out an infrastructure for a national Electronic Health Record. The way in which this infrastructure is devised is not neutral in terms of the relations it would mediate between patients, care providers and other players in the healthcare sector. Third, there are the concrete technologies or applications that such policies are expected to generate, with which patients will interact. These three ways of shaping the patient roughly correspond to what the French philosopher Michel Foucault has referred to as three modes in which people are made subjects: “modes of inquiry”, “dividing practices” and “self-constitution. I use this Foucauldian frame to examine these different aspects of innovation in healthcare. Ultimately, there is not one “subject of innovation”, but many.

Presentations at EASST: constituting people

The first days of September, me and my colleagues presented two papers at EASST2010 in Trento, Italy. EASST is the conference of the European Association for the Study of Science and Technology. Both papers dealt with the question how people are “constituted” in society, how they are given a particular role. And a bit about how they constitute themselves. Michel Foucault has written many interesting things about this topic, about which you can read a bit more in the description of my research area.

The paper that I presented (together with Benoît Dutilleul and Frans Birrer) concerned the phenomenon of Living Labs, about which we have published before. Living Labs are local platforms that involve people  in “making what they use”. By now there are 212 of such sites throughout Europe. Internationally, Living Labs are considered a “movement”. Democratisation has never been an outspoken goal, but many have argued that they may contribute to society this way. Nevertheless, they are considered undemocratic by many commentators.  In our paper, we ask what is needed to democratise Living Labs. Our idea is that this would involve re-thinking how we want people to participate, and how people might want to participate themselves. In order to examine this question, we critically examined work by Eric Von Hippel, Andrew Feenberg and what is often called the “Scandinavian tradition” of participatory design. You can have a look at the slides of my presentation below. This was part of a track on “Speculation, Design, Public and Participatory Technoscience: Possibilities and Critical Perspectives”. Alex Wilkie, one of the convenors, provides more information on his blog.

Apart from that, my colleague Frans Birrer presented our other paper about policy changes in Dutch healthcare. This is a continuation of our earlier work on the Dutch electronic health record and the patient-owned personal health budget (persoonsgebonden budget in Dutch). As part of the session ‘The shaping of patient 2.0 – Exploring agencies, technologies and discourse in new healthcare practices’, we tried to establish how patients are constituted by such major changes in policy.

Other than that, EASST was a good conference. The best I have attended so far. Over 800 presentation, many of which very interesting. A conference in Italy. With good lunch. And good coffee. Served by waitors wearing black bow ties. In the mountains.