The French philosopher Michel Foucault, in his short essay “Madness and Society,” begins by assuming what needs to be proved: that the attitude towards 'madmen' (his term) has not fundamentally changed from earlier, medieval society. In order to claim this, he makes a few assumptions: that society is divided into certain hived off components, namely, 1) labor, or economic production; 2) sexuality and family, or reproduction; 3) language/speech, and 4) 'ludic' activities such as games and festivities. These categories are fairly arbitrary, since we can see that reproduction could easily be included in production, since the reproduction of the laborer is obviously necessary to production, and of course it assumes that games have no reproductive aspect to them, which is surely at least arguable. Nevertheless, these assumptions provide the groundwork for Foucault’s hypothesis that there are 'marginalized' individual members of society who have special properties.

What Foucault calls the 'second cycle of social production' (without telling us here what the 'first cycle' might actually be) includes these individuals; his example refers to 'primitive' tribes and their celibates, homosexuals and transvestites. The justifying reference for this assertion is, however, not to members of the medieval society which preceded the modern social conditions, but the 'primitive.' The 'primitive' I suggest cannot be used convincingly to justify such claims about the medieval. Foucault is nevertheless able to assume that these individuals are marginalized because of his previous separation of categories, in which economic production is artificially segregated from the other realms, the reference to the 'primitive' is only tacked on to this.

The result is that there is no possibility of recuperation in Foucault’s account. The possibility that the (apparently) marginalized might actually be also at times culturally necessary, even central, to the reproduction of society, even if in a 'shamefaced' or de-negated way is from the outset disallowed.

Foucault’s main thesis is that the so-called difference in the modern way of treating the 'mad,' as not criminal, is mostly illusionary, and he criticizes the traditional account of history, in which modern industrial society freed 'madmen' from criminal status and entered them into the psychiatric hospital, labeling them as 'ill' for the first time. He says that it is simply not true that before the Revolution 'madmen' were regarded as criminals or that they were freed of their former status. One thing he admits though: that from the seventeenth to the 19th century the responsibility for confining a 'madman' transferred from the family to the physician. In this, he says, sexual 'anomalies' were treated as one of the main causes of 'madness.' And, with respect to language, the speech of the 'fool' was, he says (in Europe), while still being excluded and considered worthless, able to speak the truth in symbolic form 'from under the very cover of its irresponsibility.'

He relates this (rather loosely) also to modern literature: literature, in our day, has an affinity to 'madness' that it did not have up to the 19th century, literary (artistic) language is not ruled by 'the severe rule of constant truth-telling' but has become totally anarchic (here Foucault does not explain this 'rule,' or why it is 'severe,' but we may assume he means the humanist enlightenment spirit in science). So for him, European literature became especially marginal, a factor which increased during three specific periods a) in the 16th century, b) end of 18th century to the beginning of the 19th (the main example offered is Antonin Artaud, who was a schizophrenic and he, according to Foucault, opened up new vistas), c) today, where the very model for literary production is said to be 'madness.'

Turning to his example of games and festivities (such 'play' is taken for granted as being linked to art/literariness): I find it curious that in his example of games he turns to the traditional literature of the theatre, and refers to Shakespeare’s play “King Lear,” yet he does not refer to the rather more obvious role of the medieval Fool in the play to represent the spirit of madness as truth, but instead to the madness of the King. The King is a victim of his own fantasy, yet at the same time is, according to Foucault, someone who speaks the truth. Should we not suppose that for Shakespeare the Fool represented the old order of madness and the King the new, which might contradict Foucault’s assertion of there being little difference between the two kinds or notions or concepts of madness? - I will have to leave this question aside…

From here Foucault moves quickly on to the Middle Ages “Festival of Folly,” the only one which was, he says, specifically 'not religious.' In this carnival, famously, the social roles are for a time reversed: poor/rich, weak/powerful, male/female gender, and sexual prohibitions were nullified. Foucault refers specifically to the layman taking mass in church and a donkey whose braying mocked the litany. The latter I think would tend to also suggest a clue to the at least quasi-religious quality of this festival and a process of recuperation, because legitimacy can be renewed through negation, so the claim that it was not 'religious' is weakened, yet Foucault once more segregates this apparent rebelliousness from the rest of the social sphere.

We may note that intrinsic to the account that Foucault offers us is the fairly naïve idea that there really is an inside and an outside to society that one can be on and that one can therefore truly be an 'outsider'; but we know very well that the notion of the 'outsider' was increasingly romanticized in the new capitalist media. Indeed, some of the exact same literary artists that Foucault refers to produced a mythology of the artist/genius as an outsider. Without a doubt they were also keenly aware of the process of self-mythologization involved in this, which at times they do neither necessarily wholly enjoy (if it affected their actual living conditions negatively) nor considered the main value of their work, but treated the condition as nevertheless part of the job of the artist. Baudelaire is interesting in this sense because he also annuls this image in his work at the same time as he creates it, showing the reader the transactions that are taking place; Verlaine and Rimbaud take rather opposed sides in the sense of who was the true outsider (and poet), though it is a matter of degree in this case.

The concept of work plays an important part in Foucault’s analysis. Based in the idea that the vagabond could not be tolerated by the new capitalist social order because this was a person who could not fit into the new regime of work, for him it was this fact that essentially led to their confinement. If a definition of 'madness' was that they could not work, as was considered the case (Foucault refers to Freud’s profound statement), then making the 'mad' work might be good for them, and Foucault describes the new institutions for confining, watching and setting the mad to forced labor.

We can, I think, wholeheartedly agree with Foucault that the rise of the modern Hospital came in the change of an institution from one essentially of confinement (imprisonment) to that of treatment or care. This treatment involved two aspects: to confine those who were unable to work for physical reasons, and to confine those who were unable to work for non-physical reasons, such that mental disorders also became the object of medicine.

However, we must add some things: the history of the Hospital is one of slow change from early religious, monastic and charity based care or that allowed by royalty to the taking over of these functions by the modern state, which also along the way incorporated certain roles, by default and design, of the Family (the earliest true hospital seems to be Persian). And we must also take note of the medical understanding of disease and contagion and its influence on this process: separating the contagious from the general population, which represented a danger even to the rich, seemed logical. This was also partly true for the actual prison system, whose modern manifestation is supposed at least in theory to provide some degree of rehabilitation (i.e. care) as well as prevent contagion. We can also assume that all of these apparatuses shared overlapping political impetuses.

But, Foucault, we see, continues to refer to the same factor of confinement in the institutional equation. He is not wrong, but his text seems to miss the way the institution newly couches this confinement as specifically a scientifically based care. To this extent the Hospital is obliged to actually provide care, i.e. genuine services to the benefit of the well-being of the patient/inmate. Yet his is apparently an attack on institutionalized care or even its possibility as such.

We can see now how his work has been used, although in a rather roundabout way, as a justification to dismantle these institutions (or at least the apparent benefits within them) in order to provide so-called 'care in the community' (as it was called in the UK), similar to the (easily romanticized and only apparent) medieval or 'primitive' way of dealing with 'madness.' Such an attitude is also repeated again in the opposition that US President Obama (in 2009) has confronted against his plans to provide a universal health care system. (I will ignore the possibility that exists that some in the Democratic Party may not really be trying so hard and could easily be rewarded, later, for a failure that helps the vested interests.)

The mistaken support for the reactionary argument probably again stems from Foucault’s concept of 'outsider' at root, for this is a figure that is often recuperated by capitalism for purposes of reproduction of the existing relations of production (i.e. the status quo).

Allow me to explain by way of example: “Madman Entertainment” is one of the major entertainment companies in Australia; it presents amongst its list of titles the work of Lars von Trier, who produced “The Kingdom,” which was a TV mini-series about a hospital and is now a film available on DVD (there is also Stephen King’s series “Kingdom Hospital” based on it). According to Wikipedia: “The series is set in the neurosurgical ward of Copenhagen’s Rigshospitalet, the city and country’s main hospital, nicknamed ‘Riget.’ ‘Riget’ means ‘the realm’ or ‘the kingdom’ and leads one to think of ‘dødsriget,’ the realm of the dead…The show begins with the admission of a spiritualist patient, Sigrid Drusse, who hears the sound of a girl crying in the elevator shaft. Upon investigation, Drusse discovers that the girl had died decades earlier, having been killed by her father to hide her illegitimacy. In order to put the spirit to rest, Drusse searches for the girl’s body, ultimately finding it preserved in a specimen jar in the office of the hospital’s professor of pathology, professor Bondo (Baard Owe)

'Meanwhile, neurosurgeon Stig Helmer, a recent appointee from Sweden to the neurosurgery department, tries to cover up his responsibility for a botched operation which left a young girl in a persistent vegetative state.

'Pathologist Dr. Bondo attempts to convince the family of a man dying from liver cancer to donate his liver to the hospital for his research. (In fact, he wants it as a trophy, it being the 2nd largest hepatosarcoma ever recorded.) When his request is denied, Bondo has the cancerous liver transplanted into his own body (the patient having signed an organ donor form), so that the cancer will become his personal property and can be kept within the hospital…” This film plays with the contradictions of the Hospital and Family and their social role and the grim comedy they produce. But it is also a sign of how such sophisticated knowledge can itself become a part of recuperation. Its critical element is also a factor in the morbid fascination with the medical and psychological that it relies on. This is a work of art, a cultural object that produces something, or rather, it reproduces (or tries to) certain attitudes in the viewer about the conditions of life. In general cultural terms, this is the process by which the bourgeoisie continually renews its claim to being the revolutionary and progressive force in the world. It can do this, of course, only if it can continuously incorporate the 'edge' into its mainstream. Both the artistic 'left' and 'right' in this sense have their rebels that perform their duty, they each have their 'outsiders' who re-confirm the central focus of the myth of the liberal society, for only in relation to this centre, this mainstream stream, are they really 'rebels.'

This cultural reproduction is necessary to economic production, for there can be no production without reproduction (in bodily terms physically, in affections, and in ideology). So we find that the 'outsider' and sexual rebel, at least as symbolic figures, do not only appear on the edges of respectability (which of course they do, this is not to be denied) but also often re-emerge at the very centre of capitalist culture, as icons of its progress, of its universality, and may be highly celebrated in its broadcast media. What results is the kitsch imitation of the authentic artist/genius/philosopher in the guise of a popular state backed 'alternative' rebel. There are, I would venture to suggest, at least some elements of this in Foucault’s own practice as a highly celebrated philosopher. Like many philosophers before him, he valorizes his own position; he must, because it is his job to do this for the state (this is not to deny that his work is full of good ideas).

In his little essay Foucault does not mention the state. Yet the Hospital must be understood as a state apparatus, as well as the Family. And so, the transfer of responsibility for the definition of the mad person as indeed 'mad' is transferred during the period in question from one state apparatus to another, and not from an apparatus somehow or other outside the state to an apparatus inside it. In fact I think we might understand this better as a transfer taking place from one aesthetic state apparatus (ASA) to another, because it deals with the feelings and sensuality of the human subject and specifically the 'correct' alignment of these feelings for children, or 'new subjects'; but why this shift? Maybe we can assume that the social responsibility for the wayward subject was no longer trusted by the established powers to be taken care of adequately by the Family.

But we can also see that there is quite a considerable expense to be laid out in this effort, and modern bourgeois society is nothing if not thrifty if it can help it in relation to the ordinary people, and especially when this means apparently providing stuff for useless ‘crazy’ people. And yet we see there are efforts to create these massive institutions: the education system, the health system, in this period. Why?

Certainly at one point in the genesis of modern capitalist society the Family was itself being broken up by the relentless forces of capitalism, especially for the poor and the workers, and as a broken up unit it must have been seen to be of diminishing use for social control. Thus the work that had formerly been to a large extent carried out for the ordinary people by the Family (health and education) was now necessarily to be taken on more by the state. The state would at least provide certain insurances in this regard for the ruling class, even if its reach was not to be total. It provided a means of surveillance, too, and a source of statistics from which they believed (and still do) they could unlock certain secrets of social 'behavior.' At the same time it further wrested this control from the hands of the old nobility and clergy, and allowed elements of capitalist competition to enter into health and psychology (the drugs industry). One branch of the state here (the Hospital) would also act as a kind of police for the other branch of the state (the Family) and vice versa to a lesser extent, and so an equilibrium between them could perhaps be established. These institutions or apparatuses would each ensure that the ‘correct’ kind of human subject, in terms of their physical and subjective feelings, would be reproduced for the modern workplace.

Unlike the Family, the Hospital is a big institution with a somewhat collective and vague managerial system of hierarchy which fits into the even bigger social system of general health care and then is overseen by the political government of the day. This chain of command is obviously different to that of the Family, which retains a certain kind of organic autonomy from direct political influence, due to the fact that there are some underlying biological necessities that have to be performed in the Family to reproduce our species. The Hospital, however, is often charged with encroaching on the territory of the Family, and there are (justifiable) fears of a monolithic state health system that, for instance, parasitizes body parts and produces children without fathers or mothers ‘fit’ for purpose like zombies, or provides for euthanasia. On the other hand, the Hospital can also be blamed if it fails to intervene in abuses, normally of children, within the Family, (forgetting the abuses of the Hospital). There is (in capitalist society at least) always this tension between the two state apparatuses, a tension that exists exactly because they do in fact overlap in their aesthetic functions. The Health system in the UK produced or at least allowed to flourish, ironically, some of the most prolific serial killers (specifically of women) on the planet, yet at the same time abuse in the Family is a known commonplace. The two institutions share in this alike, as they do in the good things, and battles between the one and the other are missing the point, both have problems that need solutions, and setting this as some kind of gladiatorial battle is just a way of cleverly avoiding the issue.

The working class in Europe, during and after the rise of mass industry, not only fought for the Family against its dissolution but also for the benefits of universal health care, and this included mental health care; the working class were never very likely to separate how they felt about their exploitation and their mental condition of disliking it, this spontaneous materialism meant that they always considered a gain in mental health to imply or necessitate at some point a genuine social reform of material conditions of working life. Foucault here neglects to mention this struggle. And he might be taken to mean that this was because of some misguided love of monolithic controls and a ‘bad’ science.

Are there real benefits to be gained from universalized and institutionalized health care systems? Of course there are, along with the obvious horrors that any system can bring if abused and corrupted, and used as an arm of the repressive state. The latter, whilst being inevitable in a competitive economic environment to some degree, does not mean we should not seek such care, the repressive arm of the state gets along with its business quite well anyway, and in some respects may also be held in check by a well functioning health system. At its root, this is what the actual scientific discoveries of the history of the health system offers us (e.g. they do not support the pseudo science of Nazism): an idea that there are ways of living that are conducive to members of the human species feelings and sensibility, and conversely, that there are ways of living that we currently have on offer for the majority of people that are not.