A 5: Tutor submission (CTS)

A 5: Tutor submission (CTS)

Morris Gallagher 513748

Photography L3: Contextual Studies A5

CHALLENGING MEDICAL DOMINANCE IN VISUAL CULTURE: A DISCOURSE ANALYSIS

Word count with quotations (5,966)

Word count without quotations (5,489)

LIST OF ILLUSTRATIONS

Figure 1: ‘BBC News Special: Coronavirus Update 15/02/2021’ (2021) Directed by BBC. 15/02/2021; 32.06mins. At: https://www.bbc.co.uk/iplayer/episode/m000ssfg/bbc-news-special-coronavirus-update-15022021?page=4 (Accessed  16/03/2021).

Figure 2: ‘BBC News Special: Coronavirus Update 15/02/2021’ (2021) Directed by BBC. 15/02/2021; 38.05mins. At: https://www.bbc.co.uk/iplayer/episode/m000ssfg/bbc-news-special-coronavirus-update-15022021?page=4 (Accessed 16/03/2021).

Figure 3: Fildes, L. (1891). ‘The Doctor.’ [Oil paint on canvas] 1664 x 2419mm. Tate. At: https://www.tate.org.uk/art/artworks/fildes-the-doctor-n01522. (Accessed 12/11/2020).

Figure 4: Smith, E. (1948a) W. Eugene Smith | Country Doctor Dr Ceriani operating on Lee Marie Wheatly, a two and a half year old child who needed emergency surgery after having been kicked in the head by a horse. Kremmling, Colorado, USA. 1948. W. Eugene Smith. [Photograph] At: https://www.magnumphotos.com/newsroom/society/w-eugene-smith-country-doctor/attachment/par108033/(Accessed 17/06/2020).

Figure 5: Lenestan (2021). ‘Portrait of confident female doctors standing with arms crossed at the medical office.’ At: https://www.shutterstock.com/image-photo/portrait-confident-female-doctors-standing-arms-1078984250 (Accessed 18/01/2021).

Figure 6: Frare, T. and Toscani, O. (1992) ‘Man dying of AIDS’. [Poster] 299mm X 422mm. V&A Museum. At: https://collections.vam.ac.uk/item/O76080/man-dying-of-aids-poster-frare-therese/ (Accessed 10/02/2021).

Figure 7: ‘Three Oncologists (Professor RJ Steele, Professor Sir Alfred Cuschieri and Professor Sir David P Lane of the Department of Surgery and Molecular Oncology, Ninewells Hospital, Dundee).’ Ken Currie 2002, Scottish National Portrait Gallery. Oil on canvas. 195.58 x 243.84 cm. (Accessed 12/11/2020). https://www.nationalgalleries.org/search?location%5B36062%5D=36062&location%5B36105%5D=36105&location%5B36114%5D=36114

Figure 8: Giuliani, A. (2020). ‘Silvia Ligi, anesthiologist’. [Photograph] At:https://www.albertogiuliani.com/2020/05/23/covid19 (Accessed 09/10/2020).

Figure 9: Gallagher, M. (2021) ‘Visible Invisibility: Myth’. At: https://morris-gallagher.format.com/#7 (Accessed 10/08/2021).

Figure 10: Gallagher, M. (2021) ‘Visible Invisibility: Illumination’. At: https://morris-gallagher.format.com/#17(Accessed 10/08/2021).

ABSTRACT 

How is medical dominance expressed in the visual culture of medical doctors, and why does it matter? I argue that media doctor depictions are influenced by medical, government and media institutions, and societal factors, which produce beneficial and deleterious effects on the socialisation and behaviour of doctors and patients. I review the literature on medical dominance in visual culture and highlight its impact on doctor patient interactions. I employ a Foucauldian discursive approach to this medical discourse by examining the formation of medical dominance in paintings, photographs and digital media which reflect institutional representations of ‘doctors’ and their stereotypes. I begin with an analysis of the UK’s coronavirus briefing of 15th February 2021; the forces at work, its dramaturgies, myths, and strategies to control dissent. I examine the advent of the ‘new’ rational medicine of the 19th-century in Fildes,’ ‘The Doctor,’ painting (1891), an ‘ideal doctor’ from ‘small town America’ in Smith’s photo-essay ‘The Country Doctor’ from ‘Life’ magazine (1948), and the iconography of doctors in a ‘Shutterstock’ database image (2021), that all show what dominant medical image culture looks like. I identify what is coded or implied in these images, and what is excluded from these representations. Often the stereotypical, ‘hero’ doctor is dominant in these images, with the patient occupying a subsidiary role. Other types of doctor representations such as older women, people of non-white ethnicities, and ‘unhappy’ doctors feature less. I examine four other images that directly or indirectly challenge ‘dominant’ representations of doctors from an advertising poster, a museum painting, an internet image, and from my photographic practice. These images challenge institutional ideologies and regimes of representation that affect power relations and control of the body. These images are, Toscani’s Benetton poster advert of a man dying of AIDS (1992), Currie’s painting ‘Three Oncologists’ (2010), Giuliani’s digital image of a hospital worker at the start of the Covid-19 pandemic (2020), and two digital still life assemblage images from my Body of Work. I illustrate my analysis with my experiences of becoming and being a doctor. Foucault’s writings on medicine and power and Hall’s work on the formation of visual culture are key sources. I also apply Goffman’s ideas on ‘performance,’ Barthes’ theories on myths and ideologies, and Baudrillard’s theories on ‘habitus’ and ‘cultural capital’ to understanding doctor representations. Foucault concludes that differences in power between patients and doctors are necessary because patients expect a medically trained ‘expert’ to give health advice. This does not exclude challenges, as seen in this paper, by patients and others, about the misuse of power in doctor patient relationships and the organisation of health care systems. I conclude that challenges to medical dominance in visual media are essential, gradual, cumulative, and reactive to societal changes, such as in the advent of HIV and Covid-19. These visual challenges help us to think afresh about the status and roles of doctors and patients in health care interactions, and about who controls the organisation of health care, and our bodies.

CONTENTS

Chapter 1: Introduction 

Introduction

Literature summary

Methods

Chapter 2: Medical dominance in a ‘Coronavirus press briefing.’

Displays

Myths and truths

Challenges

Chapter 3: The formation of medical ideology and power

A painting: Fildes’ ‘The Doctor’ (1891)

A photograph: Smith’s ‘The Country Doctor’ (1948)

An internet image: The doctor as icon (2021)

Chapter 4: Challenging medical dominance in visual culture

Challenging culture: Benetton and the man dying of AIDS (1992)

Challenging the institution: Currie’s ‘Three Oncologists’ 2010)

Challenges to the body: Giuliani’s ‘Covid-19 | San Salvatore’ (2020)

Challenging power: My BOW ‘Visible Invisibility’ (2021)

Chapter 5: Discussion and Conclusions

Conclusions

Chapter 6: References and Bibliography

References

Bibliography

CHAPTER 1: INTRODUCTION

“…ruling groups…attempt to fashion the whole of society according to their own world view, value system, sensibility and ideology. So right is this world view for the ruling groups that they make it appear (as it does to them) as ‘natural’ and ‘inevitable’ – and for everyone – and as far as they succeed, they establish their hegemony. (Dyer, 1977;30)

Introduction

In this paper I examine medical dominance in visual culture, particularly doctor representations. This reflects my concerns about my practice as a photographer and doctor. What does medical dominance in visual culture look like, how did it originate, why are some representations problematic, how are these are challenged, and why do these concerns matter?

Starr defines medical dominance as “the power of doctors to control the actions of others through commands and cultural authority deriving from the value accorded to medical knowledge” (Starr, 1982). This control is intrinsic to systems of health care, medical, government, and media institutions, that form and reproduce knowledge, practices and systems that order power relations. Gramsci calls this dominance of one group over another ‘hegemony,’ where dominance of ideas and images is ‘hidden’ within established practices so that we accept them as ‘natural’ (D’Alleva, 2013; Rosamond, 2021). 

It is not uncommon, for example, to see a photograph of a smiling, white, male, ‘hero’ doctor alongside a patient, often a child, celebrating ‘the latest’ medical technology in a newspaper. This, and its rare counterpoint the ‘villainous’ doctor, are tropes for representing doctors; we ‘expect’ to see them in news media. They are stereotypes, a descriptive shorthand for how we see some doctors, but tend to exclude other types, such as women, Asian, LGBT+, disabled or mentally ill doctors (Dyer, 1999; Munro and Nabavi, 2020). 

Doctor representations matter because they influence how we treat them. I expect ‘my doctor’ to be brilliant and caring, like Dr Ross in E.R., and am disappointed when they don’t solve my problem and ‘dismiss’ me to explore ‘self-help’ options (Hoggart, 2000; Kiesewetter, 2020; Quick, 2009). If doctors were seen as fallible then perhaps people might have more realistic expectations of them (Phillpots, 2020). 

Hall sees the formation of visual culture as ‘elastic’ as people accept, reject, or negotiate meanings from images. These meanings feedback in a ‘circuit of culture’ to effect the production, dissemination and consumption of images by people and institutions (Hall et al., 2013). Ultimately, images of doctors’ influence what we think of doctors and how we engage with them. 

Literature summary

Medical culture has not always been dominant. In Roman times medicine was seen as a “low grade occupation” (Starr, 1982; 6). By the 18th-century doctors were unpopular, categorised as “bloody” (surgeons) or “non-bloody” (physicians), operating on “parts” and not people (Weisberg, 1995). A seismic change in doctor status began at the end of the 18th-century (Foucault, 1996;xii). This change is related to the professionalisation of medicine and is explored in Chapter 3 (Foucault, 1996; Preface).

Visual ‘texts’ that evidence the growth of medical dominance are medical portraits from 1660 to 2018 (Jordanova, 1999, 2018). They show how doctor identity, and the reputation and power of medical institutions, are constructed through symbols in doctor paintings. Our first ‘hero’ doctor, Sir Edward Jenner (1749-1823), of smallpox fame, is represented in oils and exhibited by medical and other institutions (Jordanova, 2018:87; Riedel, 2005 Jordanova, 2018, 1999). These institutionally formed images are the dominant representation of doctors in visual culture, from Rubens engraving of Hippocrates in 1638 until the 1950s and the arrival of newspaper, magazine and television culture (Rubens, 1638; Smith, 1948b; Cosgrove, 1948). 

The largest study of doctor representation analysed 5157 Australian press images, and concluded that there is a high level of ‘medical dominance’ (control) of imagery of doctors (Lupton and McLean, 1998;957). A similar Slovenian study found that doctor representations were less positive, suggesting that perception of medical dominance is culturally determined (Kovačič and Karmen, 2011).

Research about TV doctors is extensive and falls into three areas: content analysis of programmes (Chory-Assad and Tamborini, 2001; Solange, 2005); analysis of changing public perceptions of doctors (Turow, 2010; Quick, 2009; Hoggart, 2000; Feasey, 2008); and comment (Kiesewetter, 2020; James, 1989; Gazur, 2017; Verhoeven, 2008). They conclude that: doctors are represented positively; they educate viewers about health care; and the trope of the ‘Jekyll and Hyde’ and troubled hero doctor persists (Turow, 2010; Hoggart, 2000). They also recognise variables, such as the role of institutions, control of production and audience readings, which show that viewers make sophisticated contextual readings of what they view (Turow, 2010; Solange, 2005).

Women and ethnic minorities continue to be under-represented online, and ‘doctor bashing’ is a subject of study, but these are small scale content analyses (Kocemba et al., 2015; Heer-Stavert, S, 2020, 2019b; a; Wilkinson, 2021).

Contemporary research about ‘medical dominance,’ as a subject, examines cultural and societal changes that challenge the autonomy and power of doctors, and the democratisation of doctor-nurse relationships (Allsop, 2014; Whitehead and Davis, 2001). Key writers identify how the ‘sovereignty’ and control of medicine and the power and influence of doctors is being eroded by competition, governmental legislation and (financial) control (Lupton, 2003; Starr, 1982; Allsop, 2014).

There is limited substantive research examining how medical dominance is established in visual media, particularly online, and even less about alternative or challenging visual representations. This paper contributes to that gap in knowledge by identifying images that challenge medical dominance.

Methods

Foucault’s writings on medicine and power will be the lens through which I explore power relations in medical, government and media institutions and doctor patient interactions (Foucault, 1996; Chomsky and Foucault, 1971; Foucault, 1994a).

This is a medical discourse analysis using frameworks by Rose and Dijk (Dijk, 1993; Rose, 2016a; b). Medical discourse “refers to the special language of medicine, the forms of knowledge it produces and the professional institutions and social spaces which it occupies” (Nead, 1988). 

My discourse has two elements, textual and contextual. I examine visual and other ‘texts’ which will help me to delineate structures, practices and power relations, as in doctor and patient roles. I will explore how social, political, and cultural factors affect the production and consumption of visual media, with an emphasis on how that creates and sustains medical ideology and hegemony. I will examine institutional practices, their ‘spaces of observation,’ the ‘day to day’ work of doctors, and compliance by patients, that reinforce systems of health care that subjugate patients and doctors, and bolster medical and governmental power (Foucault, 1977;135). I will also identify problems with representations, what is missing or neglected, and investigate ‘alternative’ photographic depictions that challenge medical dominance in visual media. 

Hall, Goffman, Barthes, Baudrillard and other writers also contribute to my theoretical framework (Hall et al., 2013; Goffmann, 1956; Barthes, 1957, 1977; Huang, 2019).

In summary, this paper explores medical dominance in visual culture; what it is, what it looks like, how it is formed, why some representations are problematic, how they are challenged, and why dominance matters. Foucault’s writings on the formation of medical culture and power, and Halls’ theories of cultural representations are my main sources for this discursive analysis.

CHAPTER TWO: MEDICAL DOMINANCE IN A ‘CORONAVIRUS PRESS BRIEFING.’

Displays

Do institutions control people’s responses to medical images and knowledge?  Figures 1 and 2 are images from a televised ‘Coronavirus Press Briefing’ (BBC News Special: Coronovirus Update, 2021). This was aired after the second wave peak of cases when 15 million people had received their first vaccine.

Figure 1: Screensave of BBC News Special: Coronovirus Update 15/02/2021, 2021; 32.05 mins https://www.bbc.co.uk/iplayer/episode/m000ssfg/bbc-news-special-coronavirus-update-15022021?page=4 

Figure 2: Screensave of BBC News Special: Coronovirus Update 15/02/2021, 2021; 38.05 mins https://www.bbc.co.uk/iplayer/episode/m000ssfg/bbc-news-special-coronavirus-update-15022021?page=4 

The denotative aspects of this video are that three people enter a room to stand behind wooden lecterns with placards that say, “STAY HOME – PROTECT THE NHS – SAVE LIVES.” Screen texts inform us that this is the ‘Prime Minister, Mr Boris Johnson,’ flanked by the ‘Chief Medical Adviser, Dr Chris Whitty,’ and ‘Chief Executive Officer of the NHS, Sir Simon Stevens.’ The Downing Street logo fills a TV screen to the left of the room and a suited man is signing speech to the right. The room is wood-panelled, with elaborate light holders, a bright patterned carpet in front of the speakers and unfurled Union Jack flags are visible in an anteroom (Fig 1).

The connotative aspects of these scenes are that three institutions orchestrate a display. The first institution is a broadcasting company where “Governments set the terms under which it operates, they appoint its most senior figures, …it hardly amounts to independence” (Mills and Sinclair, 2017). While the BBC continues to promulgate its ‘independence’ and role as ‘truth teller,’ it also pursues nationalistic ideals and actions where “nation shall speak truth unto nation” (Boaden, 2011).

Next, the institute of government is represented by its prime politician and two senior medical doctors, who represent medical institutions and are answerable to politicians. This is a display of governmental, media and medical power; power within power, within power. 

My content analysis of participant’s speech identified two main themes; “the vaccine rollout is going well’ and ‘there is still a threat.’ The commonest word used after “vaccine” was “high” or “very high.” The Prime Minister’s celebrates “powering past the targets we have set,” helping “vulnerable people” (the third most used phrase) and being cautious for the future. The context of this briefing is that it pre-dates a “road map” for reducing pandemic constraints amidst pressure from Conservative politicians and sections of the media to release social restraints; they are the target audience for this briefing. 

Myths and truths

Several myths are coded in this tableau of signs (Barthes, 1977:33-35). The first myth signified is ‘war briefings’ from the 1940s, with signifiers of the Union Flag, panelled room, and “No 10”, that reference war successes and notions of ‘Empire’ such as the ethnocentrism of Brexit. The Prime Minister ‘wrapped’ in the Union Jack also signifies past glories of when Britain was ‘Great,’ and references the success of British technology to produce a successful vaccine (Johnson, 2014). This analogy is inferred yet understood by viewers; “… it postulates a kind of knowledge, a past, a memory, a comparative order of facts, ideas and decisions” (Barthes, 1957:226-7). These ideological systems, whose meanings and messages are orchestrated here, are founded on culture, knowledge, and history, and are read and understood by viewers who, at a distance, share and reprise responses to these myths.  

A counterpoint to myth is truth; can the audience know that what is presented is truthful? Goffman, in his analysis of behavioural performances discusses inauthentic performances or ‘false fronts,’ which he defines as “a discrepancy between fostered appearances and reality” (Goffmann, 1956:66). ‘Front’ refers to settings, and the performers’ appearances and manner. Goffmann says that we can infer falsity and ‘secrets’ from what is said, but we are unlikely to be able to define its substance if the performance is well constructed and ‘believed’ by presenters and audience (Goffmann, 1956;77). He concludes that, “…the real secret behind the mystery is that there really is no mystery” and that these secrets are “petty ones” (Goffmann, 1956;76). Perhaps that is the case with Boris Johnson’s attempt to defend his aide Dominic Cummings, about breaching Covid-19 regulations, in the Covid-19  briefing of May 2020? (Duncan, 2020). There was a ‘secret’ reason for Cummings’ strange behaviour, which was later revealed to be information about personal security: a far cry from an explanation about ‘driving blind’ in Barnard Castle (Shaw, 2021).

Challenges

One might argue that medical and political dominance in Covid-19 policy is a ‘preferred’ response; it is natural, ideological, and hegemonic. The problem is that not everyone shares an ideological view which leaves little room for disagreement or counter narratives, such as anti-masking and criticism of coronavirus deaths. 

Foucault comments that systems of power always include strategies to nullify dissent, “every relationship of power tends, both through its intrinsic course of development and when frontally encountering resistances, to become a winning strategy” (Foucault, 1994a;346). There are three elements to Foucault’s conception of ‘strategy:’ a description of means to achieve a certain end; to consider how the audience will react; and employing procedures to make them desist (Foucault, 1994a:346-7). It is this last strategy of a carefully constructed question and answer section in this briefing, where strident questions from journalists are ‘neutered,’ so that control remains with the presenters and “Stable mechanisms replace the free flow of antagonistic reactions” (Foucault, 1994a:346-7). The leaders of this meeting vigorously control what is sayable and ignore or reflect disagreements, while superficially giving the appearance of public accountability. 

In summary, I have shown that three powerful institutions produce a regime of representation with visual and textual practices about medical knowledge of how to manage a pandemic, rules about talking about the pandemic for resisting counter narratives, and practices for dealing with people – its polities. I have also commented on the impact of shared government and audience myths used to promote identification with ideologies, and the role of ‘Front,’ inauthentic performances, and truth in this briefing (Dyer, 1977: 30). 

CHAPTER 3: THE FORMATION OF MEDICAL IDEOLOGY AND POWER

In this chapter I take a discursive approach to examining three images that show how medical, governmental, and media organisations have formed systems of health care and control that have helped shape doctor and patient behaviours and roles. 

Foucault marks a paradigm shift in medicine at the end of the 18th-century, when old ideas about medicine were challenged with resultant radical changes in health care, doctor behaviour and social relationships (Foucault, 1996;xviii). Medical knowledge changed from a ‘mythological’ understanding of disease to one based on evidence of disease that could be observed, measured, and debated; a world of “constant visibility” (Foucault, 1996;x). Practices of studying pathological anatomy took place within a new institution, “the clinic,” where hitherto poorly trained and paid doctors were inculcated into the ‘new’ observational medicine and certified as fit to practice by new institutions – medical schools.

A painting: Fildes’ ‘The Doctor’ (1891)

Weisberg argues for a pivotal moment in medical portraiture in French painting in 1880 when portrait conventions changed from “blood” surgeons and “non-bloody” physicians to being at the patient’s bedside (Weisberg, 1995; Michelena, 1887). Fildes painting ‘The Doctor’ (Figure 4) is a British example of this new genre (Fildes, 1891). 

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Figure 3: Fildes, L. (1891). ‘The Doctor.’ [Oil paint on canvas] 1664 x 2419mm.: Tate. At: https://www.tate.org.uk/art/artworks/fildes-the-doctor-n01522. (Accessed 12/11/2020).

In Fildes’ picture we see a well-dressed man contemplating an ill child at their ‘bedside.’ The child’s arm is outstretched to the doctor. A father and mother look on from the shadows. On the table is a bottle of medicine, cup, and spoon. A crumpled paper lies on the floor and there is water and a bowl on a trestle at the head of the bed. 

The connotative aspects of this scene are that this a vigil of a doctor in a patient’s home. The furrowed brow of the doctor references iconic images of Asclepius and Hippocrates (Rubens, 1638). The half-full medicine bottle and filled prescription paper signify that this physician is a trustworthy dispenser of medicine and not a ‘quack.’

In the early decades of the nineteenth century there continued to be a blurred boundary between legitimate physicians and those “peddling illegitimate medicine and false knowledge” (Morrison, 2016). Foucault remarks on the effects of the new medical institutions on doctors, “supervision would be exercised over the doctors themselves, abuses would be prevented and quacks forbidden to practice,” by structured, scientific medicine based in the patient’s home (Foucault, 1996; 19-20). Here we discern the beginnings of self-monitoring of doctors by medical institutions, the application of new knowledge to disease, and an intention to place health care in the patient’s home. 

A paradox of medical and governmental changes in France and the UK is that ridding society of quacks created a medical elite with increased power over medicine and health care and people’s bodies (Morrison, 2016).

Foucault describes two “great myths” driving medical change after the French Revolution of 1789-9; the nationalisation of a medical profession that will improves men’s bodies, and being able to eradicate disease and restore health (Foucault, 1996;31-32). Both myths medicalise a society staffed by “priests of the body,” and health monitoring in an “organised, and ceaselessly supervised environment” (Foucault, 1996;32). These myths continue today as ‘hero’ doctors ‘battle’ disease, and the NHS monitors patient adherence to regimes of care, as in the case of diabetes and other chronic diseases. 

This painting, commissioned by Tate, is problematic because it is an advertisement for a ‘new kind of doctor.’ The high-status doctor depicted would not have visited this cottage, it would have been a poorly paid physician. Working people, in local community medical contracts, had good access to doctors, while the middle and upper classes paid fees for services, and doctors prospered from patronage. The myth of this painting is of “a common child being treated like royalty by an agent of modern magic, the ‘Doctor of Medicine’” (Morrison, 2016). 

A photograph: Eugene Smith’s ‘The Country Doctor’ (1954)

In contrast to Fildes’ construction of the doctor and patient relationship and institutional power, Smith’s photojournalistic image of a similar scene (Figure 5) displays new features of power relations (Smith, 1948a).

A group of people

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Figure 4: Smith, E. (1948a) W. Eugene Smith | Country Doctor Dr Ceriani operating on Lee Marie Wheatly, a two and a half year old child who needed emergency surgery after having been kicked in the head by a horse. Kremmling, Colorado, USA. 1948. W. Eugene Smith. [Photograph] At: https://www.magnumphotos.com/newsroom/society/w-eugene-smith-country-doctor/attachment/par108033/ (Accessed 17/06/2020).

In this image four people, two women and two men, intently observe something out of frame. The anchoring text tells us that Dr Ceriani is operating on a child that has been kicked in the head by a horse. The doctor and other participants are dressed alike and a man in the background, perhaps the father, wears a Stetson hat. Unlike Fildes’ painting the family are not in shadow but occupy the space of this picture, but the most striking feature of this image is that the patient is invisible (Moore, 2008; Foucault, 1996). This image says that it is the medical act that is important and not the patient. This is a conscious decision by the photographer, although we see the child’s sutured head in another photograph in this article. It is a picture of power relations, of a proactive ‘hero’ doctor and passive patients and family who act as ‘extras’ in a medical drama that harks back to before Fildes’ time and anticipates what we continue to see today in medical TV soaps.  

Another denotative aspect of this image is the intimacy of spatial and personal relationship engaged to health care. The setting suggests a clinic rather than the patient’s home, the site of the technology of operations. Dr Ceriani’s examination gaze is shared by everyone in the frame. The stethoscope is absent, but an examination light demonstrates that this is not ‘show’ but used to explore a huge facial wound. Armstrong sees power much less in structures, but in “the rash displayed, the hand applied to the abdomen, the stethoscope applied closely to the chest. This is the stuff of power. Trivial perhaps but repetitive, strategies…” (Armstrong 1987). 

This image was mass produced as part of a series in ‘Life’ magazine (Cosgrove, 1948). ‘Life’s’ pages contained aspirational advertisements and features promoting the myth of small town America as “the ideal place” to live, where patients could expect to be cared for by this ideal doctor (Webb, 2006). We return to Hall’s and du Gay’s ‘circuits of culture’ model where repeated consumption of images help shape viewers identities and personal ideologies (Hall et al., 2013a; Lewis, 2007). Audiences identify with and value images which connect with personal concerns and values; they are not merely ideological expressions of medical and media knowledge and institutions. 

An internet image: the doctor as icon (2021)

Figure 5 is an image from the media company ‘Shutterstock’ (Lenestan, 2021). It includes iconic objects that denote ‘doctor;’ stethoscope, scrubs, nametag, white coat, and portable computer.

A person wearing a stethoscope around her neck

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Figure 5: Lenestan (2021). ‘Portrait of confident female doctors standing with arms crossed at the medical office.’ At: https://www.shutterstock.com/image-photo/portrait-confident-female-doctors-standing-arms-1078984250 (Purchased and Accessed 18/01/2021)

From its invention by Laennec in 1816 the stethoscope became an icon signifying ‘doctor’ (Reiser, 1993). We see it draped around George Clooney’s neck in the TV drama ‘ER,’ as visual shorthand that signifies the role of Doctor Ross (Kiesewetter, 2020). For Foucault “The medical gaze is now endowed with a pluri-sensorial structure. A gaze that touches, hears, and moreover, not by essence or necessity, sees” (Foucault, 1996;164). This is an epistemological change in knowledge where the invisible heart and lungs of the body is made audible, and hence visible to our senses; a demonstration of  “invisible visibility” (Foucault, 1996;165).

The stethoscope can also be viewed as a performative object that demonstrates doctor identity, skills and status, intrinsic to the ‘habitus’ of doctors (Rice, 2010; Lau, 2004; Barcelos Neto, 2003; Miller, 2005; Huang, 2019). ‘Habitus,’ a concept by Bourdieu, tells us that individuals develop attitudes, approaches and practices which help them “become themselves” (Webb et al., 2002;xii-xiii). As a medical student I learnt abnormal heart sounds from listening to a record, and with the guidance of my teachers, peers, and difficult competency ‘tests’ began to ‘master’ this new technology. This is the professional socialising function of medicine where beliefs and knowledge about diagnosing illness and responding to patients are absorbed (Lupton, 2003;127). Bourdieu, in his concept of ‘Cultural capital,’ also identifies the influence of social networks and economic advantage which, in this context, are formed in the social, professional and power relationships of doctors training in medicine, and helps to differentiate ‘doctors’ form ‘non-doctors.’ (Huang, 2019). 

This image is ‘anomalous’ because women doctors, particularly older women, are less represented in visual media than men (Shilcutt and Silver, 2018; Jordanova, 1999). It challenges the dominance of images of male doctors, although it also exploits women by presenting them as a commodity to purchase for display to media and other audiences (Hall et al., 2013). 

Several things are absent in the images I have chosen: the patient as expert of their own care; the uncertain and distressed patient, doctor, carer, or health care worker; older women, people from ethnic minorities, and those with disabilities. Where are these visual challenges? 

In summary, I have identified several features of representations of doctors and patients in visual media. These include images that enhance the status of doctors at the expense of patients, socialising practices related to medical paraphernalia and practices, and neglected representations of patients and doctors. 

CHAPTER 4:  CHALLENGING MEDICAL DOMINANCE IN VISUAL CULTURE

Foucault describes a symbiotic relationship between power and its critique, “Where there is power, there is resistance…” (Foucault 1976:95). What does that resistance look like and where might we find it?

Resistance to power is seen in practices such as ‘discursive resistance,’ and ‘reversed’ discourse (Lilja, 2018). Discourse resistance can be defined as ‘everyday’ actions, like a complaint about a doctor, that collectively challenge power. ‘Reversed’ discourse’ refers to reactions to a particular discourse, such as the construction of homosexuality as an ill, which we examine in our next section (Foucault, 1990:101-2).

Foucault sees “no single locus of great Refusal” but an abundance of resistances manifested in multiple ways (Foucault, 1976;96). The four images in this chapter, together, are an example of collective resistance.

Foucault suggests multiple domains where resistance to power relationships is expressed. These include cultural differences, institutional structures and surveillance of the body (Foucault, 1994b;344). These three areas, and an example from my Body of Work (BOW), are my framework for examining challenges to medical dominance. 

Challenging culture: Benetton and the man dying of AIDS (1992)

Figure 6 is Toscani’s poster of a man dying of AIDS, which was included in an advertising campaign by the company ‘United Colours of Benetton,’ challenges medical and advertising culture (Frare and Toscani, 1992).

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Figure 6: Frare, T. and Toscani, O. (1992) Man dying of AIDS. [Poster] 299mm X 422mm.: V&A Museum. At: https://collections.vam.ac.uk/item/O76080/man-dying-of-aids-poster-frare-therese/ (Accessed 10/02/2021).

To the left of the image is a dying man in a bed, whose head and arm are cradled by a man’s head and arm and another person out of frame. To the right a woman views the scene and embraces the body and head of a young girl, mirroring the embrace of the dying man. The logo ‘United Colours of Benneton’ occupies the bottom right-hand corner of the image. This poster was originally titled “Final Moments” confirming that this is a death scene. 

This is a photograph of the death of the American AIDS activist David Kirby. He looks like the face of a dying Christ, observed by an icon of Jesus with hands outstretched above him directing the scene. We begin to view this as a religious tableau as when Jesus’ followers comforted the ‘sacrificial lamb’ and Mary and other followers looked on (THB, 1991).

Replacing Christ with a gay man dying of an illness and “unnatural sex” was shocking as it crossed religious, moral and gender boundaries. It shattered conventions of that time about advertising and medical representations about AIDS. Foucault sees this as a “’reverse’ discourse: homosexuality began to speak on its own behalf, to demand that its legitimacy or ‘naturality’ be acknowledged” (Foucault, 1990:101-2). 

Little was known about AIDS for several years; ‘biopower’ from health institutions and pharmaceutical companies to find a ‘cure,’ and ‘biopolitics’ from governments to control the disease had few answers. That void was filled by gay men who challenged negative narratives and images of gay men and governmental responses to HIV, as exemplified in the film ‘Dallas Buyers Club’ (Dallas Buyers Club, 2013). We see a challenge to power relations that  “control the social body and oppress or repress it” (Chomsky and Foucault, 1971).  

Challenging the institution: Currie’s ‘Three Oncologists’ (2010)

A painting that challenges painterly conventions about doctor representation is Currie’s ‘Three Oncologists’ (Ken Currie: Three Oncologist, 2010). 

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Figure 7: ‘Three Oncologists (Professor RJ Steele, Professor Sir Alfred Cuschieri and Professor Sir David P Lane of the Department of Surgery and Molecular Oncology, Ninewells Hospital, Dundee).’ Ken Currie 2002, Scottish National Portrait Gallery. Oil on canvas. 195.58 x 243.84 cm. (Accessed 12/11/2020).https://www.nationalgalleries.org/search?location%5B36062%5D=36062&location%5B36105%5D=36105&location%5B36114%5D=36114

The denotative aspects of this image are that three ‘spectral’ looking characters pull back a curtain to blackness. The iconic surgical gowns, white coat, masks, surgical caps, and bloodied gloves signify that they are two surgeons and a physician. Their faces are haunted; these are not newspaper images of smiling ‘hero’ doctors or the ‘powerful’ institutional gazes of Victorian portraiture. The gloves and gowns reference the ‘bloody’ surgeons of Rowlandson’s time (1809), but there are also the new ‘technologies’ of the endoscope and notepad (Rowlandson, 1809). The image title tells us that these are named oncologists from Dundee.

The connotative aspects of this image are that these doctors occupy a liminal space between ‘life giving’ and death (and cancer). They appear as Foucault’s “priests,” yet, like their patients, they seem scared and scarred by their experiences (Foucault, 1996;32). Their expressions express their humanity and not their knowledge or omnipotence. They carry with them knowledge (notepad), technology (endoscope), surgery skills (bloodied gloves) and their humanity.

We also see the apparatuses of “biopower,” but not the exultation of their status and ‘mastery of illness’ (Foucault, 1996;31-32). These doctors know that the power to eradicate and restore people’s health, one of the driving forces of a re-configuring health care in the 18-19th-century, is not something that they can control (Foucault, 1996;31-32). 

Challenges to the body: Giuliani’s ‘Covid-19 | San Salvatore’ (2020)

Foucault comments that the body is a “political field” where power relations directly affect and control the body (Foucault, 1977;25). This “hold” on the body is exercised daily when a patient enters a GP surgery; the receptionist ‘checks’ their arrival, like others, they sit ‘still’ in a waiting room, and await the summons to a ‘body’ consultation with ‘the doctor.’ The receptionist observes from a desk which looks “like the bridge of the Starship Enterprise;” as a patient I am observed and regulated (Gallagher, 2003;150). This is a central experience of Foucault’s analysis of ‘panopticons’ where a person’s behaviour is constrained and modified by the organisation of power and associated surveillance (Foucault, 1978: 202-3; 2008).

In Giuliani’s photographic series of Italian doctors and nurses, taken at the beginning of the Covid-19 pandemic in March 2020, we see bodies marked by caring for covid patients (Giuliani, 2020). Figure 8 is an image of the anaesthesiologist Dr Silvia Ligi at the end of her twelve-hour shift. 

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Figure 8: Giuliani, A. (2020). Silvia Ligi, anesthiologist. [Photograph] At: https://www.albertogiuliani.com/2020/05/23/covid19 (Accessed 09/10/2020).

The woman is dressed in a disposable blue gown, green home-made scarf and head covering. The scarf is frayed and a home-made name ‘tag’ is affixed to the gown with skin tape. She looks askance at the photographer; there is a question there, but I am not sure what it is. Her face in bruised and marked with two diverging red lines which emanate from in front of the ear, which appear to cut into the skin. It is only the anchoring text that tells us that this is Silvia Ligi an anaesthetic doctor. 

Like Currie’s ‘Three Oncologists’ the smiling powerful self-confident gazes of prominent doctors is replaced by an uncertain and powerless gaze in response to a new and difficult foe. She is caught in a forcefield of the body that “mark it,” as in the scars of prolonged mask wearing, “force it to carry out tasks,” such as ventilating people with breathing problems, “to perform ceremonies,” as in treatments, and certifying deaths, and “ to emit signs,” in this case, of doctor and patient suffering (Foucault, 1977;25).

Challenging power: My BOW ‘Visible Invisibility’ (2021)

My work is a critique of power relations in the Covid-19 pandemic. In my research into ‘images of Covid-19’ I was struck by an absence of anger and reproval of the UK governments response to covid in institutionally commissioned and curated images of the pandemic (Historic England, 2020; Format21, 2021). I wanted to challenge governmental narratives of the pandemic. My tutor Gary Clarkson, suggested assemblage as a medium of expression, as in the work of Man Ray and Sarah Lucas (Man Ray, 1944; Lucas, 2019).

Figure 9 contrasts with Figure 1. This is a still-life of an overturned iconic Union Flags, with ‘Nipper,’ of ‘His Masters Voice’ gramophone company, beside a lectern observing the scene. The discarded Union Flags signify that their association with ‘Great Britain’ are anachronistic and without substance. Normally ‘Nipper’ is attentive to His Master’s Voice but here he is uncertain about the scene that he surveys. The Covid briefing displays the power and ideologies of three institutions but at times that display has been chaotic, disingenuous, and impotent to make good decisions for us the audience.

Figure 9: Gallagher, M. (2021) Visible Invisibility: Myth. At: https://morris-gallagher.format.com/#7 (Accessed 10/08/2021).

In Figure 10 is a small and a large torch alongside a pile of ashes. The ashes are meant to represent all those who have died with Covid-19. My intention was to shine a light on the excessive number of Covid-19 deaths in the UK, perhaps related to delayed lockdowns by the government. The recent parliamentary enquiry into the covid pandemic has been time and subject limited, as signified by the small light, which is not as illuminating as that which could come from a big light source (and bigger enquiry) to the left of the picture. 

Figure 10: Gallagher, M. (2021) Visible Invisibility: Illumination. At: https://morris-gallagher.format.com/#17 (Accessed 10/08/2021).

In summary, I have presented four sets of images that challenge visual representations of doctors and health care. These show that it is possible to produce artworks that challenge dominant medical representations and ideology and ask questions about power relationships in health care.

DISCUSSION AND CONCLUSIONS

Three questions arise from my paper: is it desirable to challenge medical dominance; what are the constraints to that challenge; and what would a visual culture look like that incorporated resistance?

Is challenge necessary? 

From this paper you could surmise that medical dominance is harmful, but Foucault concludes that “social order and conformity” are necessary to meet the expectations of patients and doctors (Lupton, 2003;121). Doctor patient consultations depend on a differential of power between the patient and doctor, as discourses and practices of medicine are founded on the doctor continuing to occupy the role of expert (Lupton, 2003;121). 

To counter this Foucault sees an “imperative” to challenge power abuses (Chomsky and Foucualt, 1971; Lupton, 2003;121). That challenge is intrinsic to power relations, so much so that institutions organise to nullify expected dissent (Foucault, 1994b: 95). 

A primary function of health care systems, like the NHS, is to control, classify and monitor disease, with regimes of control that frame patient doctor/nurse interactions. Individual and collective ‘reactions’ to this ‘system’ include the growth of self-care, self-help groups and a rejection of technology such as vaccination (Lupton, 2003). The NHS also employs strategies aimed at helping patients to ‘challenge the organisation,’ by patient surveys and forums. The evidence is that these initiatives validate care decisions but restrict knowledge to disable effective patient contribution (Currie et al., 2018). As Foucault has shown, the impetus of institutions is to control and dissipate dissent while giving the appearance of ‘listening’ and responding. 

My literature review shows that online representations continue to underrepresent women doctors and other groups, but online and special interest groups is where criticisms about health care is most expressed (Snowdon, 2020). Sometimes these ‘pressure’ groups influence mainstream care, as in the recent contaminated blood scandal (Factor8, 2021). For the most part this resistance does not impinge on ‘regimes of truth,’ that determine what knowledge is valued and promoted in health care, which continues to boost “the status of those who are charged with what counts as true,” i.e. doctors, government and the NHS (Foucault, 1980;131).

What are the constraints of challenge?

Photographic challenges to power seem to centre around the body, medical ‘gaze’ and surveillance, as in the work of Jo Spence and Sally Mann  (Jo Spence, 2020; Mann, 2003). They are less likely to overtly challenge medical or institutional power. 

Perhaps challenging the ‘body’ relates to its immediacy as an object for observation and exhibition, and ‘hidden’ institutional power is by nature opaque and not easy to show. Another reason for avoiding ‘necessary’ institutional challenge is that those institutions are prepared to ‘push back’ on that challenge.

My experience of photographing a ‘resisting’ group, NHS whistleblowers, has been sobering. I interviewed a group of prominent whistleblowers who had all complained about patient safety. They were ‘punished’ with counter allegations and expensive litigation by powerful hospital Trusts (sic) (Gallagher, 2018). I decided not to publish my work because I was at risk of the same litigation, financial loss and opprobrium; the powerful NHS ‘Goliath’ can be ruthless at protecting their hegemony (Francis, 2015; Armstrong, 2018).

Challenge also tends to be reactive to events, as in my BOW about Covid-19: resistance to power ‘waits’ for the exposure of an abuse of power relations for resistive action (Foucault, 2007;46-7). 

A responsive visual culture

Could the paradigm shift in health care at the end of the 18th-century recur? (Foucault, 1996;xviii). Would an inversion of power produce different images of doctors and health care, and effect how we relate to them? There are echoes of change today with more women doctors in visual media and minority or pressure groups increasingly have their say in news media. I have also identified several images in this paper that challenge institutional power.

For Foucault there are “no great radical ruptures…more often one is dealing with mobile and transitory points of resistance, producing cleavages in a society that shift about, fracturing unities and effecting regroupings…” (Foucault, 1990;96). Power and control within medical culture is entrenched is that it is slow to respond to societal changes. The nature of resistance to medical hegemony in visual culture is that it is cumulative, uncertain, and temporal, but visible and sometimes, rarely, transformative.

Conclusions

Power is embedded in media, governmental and medical institutions, and practices. This ‘hidden’ power is expressed in paintings, magazines, newspapers, on TV, online and in artworks. 

Medical dominance and doctor behaviour is formed by the practices of medical schools, certification, the ‘professional’ socialisation of doctors, and systems of health and body monitoring. Government, media, and advertising institutions, with feedback from patients, helps to form and control doctor representations.  

Doctors are overrepresented in visual media, compared to patients and other doctor groups such as women, older workers, and people from non-white ethnicities. These doctors are often ‘hero’ stereotypes or notable local figures.

Doctors’ representations effect how we relate to doctors in medical consultation and as groups and are determined by institutional and medical practices as part of a ‘circle of culture.’

Power differentials in medical relations have a social utility for effective medical consultations, yet this relationship continues to be open to challenges about misuses of power.

Challenges to dominant presentations of doctor images are often opportunistic and reactive to misuse of power. Institutions strategise to nullify criticism, but alternative representations continue to challenge to medical dominance in visual culture.  

REFERENCES AND BIBLIOGRAPHY

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