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Abstract

Utopianism is philosophy embodied in utopian texts (e.g., Thomas More’s Utopia) or in utopian practices (e.g., transformative social movements).

More’s Utopia is an exemplar of an enlightened utopianism articulating humanistic values of the Renaissance and early Enlightenment. Education and pedagogical reforms are seen as conditions of possibility of a good life within the state. Health is a basic value in enlightened utopianism either achieved by self-care of enlightened citizens (Thomas More) or by an emerging medical science securing cure of disease and prolongation of life (Francis Bacon).

Transformative utopianism is based upon shared human experiences of vulnerability and weakness. It is associated with classical medical values of modesty in contrast to medical omnipotence being hoped for by Baconian kinds of enlightened utopianism.

Enlightened and transformative utopianisms are ideal types. Many concrete examples of utopianism are mixtures of these types.

Enlightened utopianism and transformative utopianism embody different ethical perspectives relevant to global bioethics. Kantian versions of utopianism aim at global justice based upon universal principles and international law. Contemporary transformative utopianism points to the signiﬁcance of a historical narrative about people aiming at a better life for the disadvantaged and gives voice to the weak and oppressed.

Introduction

The English lawyer and social philosopher Thomas More coined the word “utopia.” More’s Utopia (1516) is ﬁctional and about an ideal that no place meets. Utopia derives from Greek and means “no-place.” Through a homonym in Greek utopia has mistakenly been understood as “good place.” In the Oxford Learner’s Dictionary utopia is deﬁned as “an imaginary place or state in which everything is perfect.” The deﬁnition reﬂects an ordinary understanding of utopia as wishful thinking and ideal state of affairs not to be realized in human history. Several famous treatises exemplify the deﬁnition. Plato’s Republic (380 BC) about a state governed by philosopher kings and Plutarch’s The Life of Lycurgus (75 AC) about Sparta as a commonwealth and an example of perfect social cohesion are probably the oldest known examples of utopia as deﬁned in the dictionary.

Utopia remained for a long time after the publication of More’s book a proper name. In the eighteenth century utopia signiﬁed a genre or text and at the end of the eighteenth century authors of utopian texts and systems were called utopians. Today utopianism refers to the kind of thinking or philosophy articulated in utopian texts or utopian practices. So, utopia may take many forms and may at its broadest be deﬁned as expressions of desires for a better way of living (Bloch 1995). Some utopias are transformative and imply a commitment to social change. The German philosopher Ernst Bloch called such utopias anticipatory or concrete. Anticipatory utopias are to be distinguished from utopias that are fantasies and escapism.

Utopianism takes different forms. Enlightened utopianism ascribes a central role to teaching and instruction of people as a way to promote better ways of living. Experts deﬁne goals and develop means to try to reach these goals in an imagined utopian world. In transformative utopianism communal practices or collaborative efforts (e.g., the state, the church, the health care system, or local communities, movements or organizations) are assumed to be the basic vehicle of social transformation toward a better life in the community. Enlightened and transformative utopianisms are ideal types. Concrete examples of utopias and utopianism (e.g., contemporary techno-scientiﬁc utopias) are often a mixture of enlightened and transformative utopianism.

Medicine and health care practices have played crucial roles in most utopias or forms of utopian thinking. This should be no surprise. Since Antiquity, the telos of medicine has been health (deﬁned in various ways but always embodying ideas of a better life and possibilities of ﬂourishing in contrast to a life limited by disease and threats of premature death). So in accordance with the definition of utopianism above, medicine is utopianism or part of more encompassing examples of utopianism.

Enlightened Utopianism

More’s Utopia is a country of abundance. There is no private property. People don’t have to run households. Unless people want to prepare their own meals, they eat together with fellow beings. Every person lives in the countryside and acquires skills in various essential crafts. People only have to work 6 h a day. Work is a burden which all have to share. So, here’s plenty of time for culture and learning.

According to the French philosopher Michèle Le Doeuff “the major concern of utopia is to focus thought on the conditions of possibility for optimal or maximal public (or state-controlled) education” (Le Doeuff 1982, p. 447). For More, the basic demand of reason is to develop one’s mind. The state interferes as little as possible in social life in Utopia. Interference and control is not necessary because public instruction results in enlightened and good citizens. More’s Utopia is an exempliﬁcation of humanistic ideals of the Renaissance.

Civic education is achieved through instruction. Utopia is a vision of a kind of a democratic society. There are, however, people who acquire a special position in society, a “company of learned men.” This elite of experts does not possess a special, sacred knowledge unavailable to other citizens, but they have got time and opportunity to cultivate the knowledge assumed to be essential to everybody in Utopia.

More’s political philosophy is in important respects similar to the political philosophy expressed by Francis Bacon in his The New Atlantis (1627). Bacon’s new Atlantis is a utopian land called Bensalem. In Bensalem science plays a crucial role in promoting human and social ﬂourishing. An institute of scientiﬁc and technical research (“House of Salomon”) is according to Bacon the noblest foundation of the new Atlantis.

More’s and Bacon’s Utopia (and a third important Utopia Campanella’s: The City of the Sun (1602/1623)) were written in the aftermath of far-reaching social and political transformations in Europe. Three great modern states (France, England, and Spain) were created. The idea of the nation emerged at the same time as modern states that were concerned with pedagogic reforms to emancipate knowledge, which until then had been monopolized by the Church (Le Doeuff 1982, p. 459).

Utopianism is sometimes characterized as wishful thinking or dreaming without connection with social reality. More’s, Bacon’s, and Campanella’s utopias tell a different story. They all present pedagogical projects that reﬂect important social and political tendencies in their respective societies: a crucial social role is ascribed to a group of people, teachers, experts trained in disciplines and crafts besides theology, and needed by the modern state. According to Le Doeuff “the projection of values and hopes of the new caste” was written into the utopian texts (le Doeuff 1982, p. 461). These texts articulate the idea of an intimate connection of the pedagogical and the sociopolitical.

Medicine And Enlightened Utopianism

According to More, people in Utopia distinguish between different kinds of pleasure. The regular functioning of the body i.e., a state of health, which is not disturbed by ailments, ﬁlls the whole organism with a conscious sense of enjoyment and physical pleasure.

The Utopians, says More, reckon it the foundation and basis of all the other joys of life since this alone makes the state of life easy and desirable. Health “results from an undisturbed and vigorous constitution of body, when life and active spirits seem to actuate every part.. .. This lively health, when entirely free from all mixture of pain, of itself gives an inward pleasure, independent of all external objects of delight” (More, p. 114). But how do people in More’s Utopia promote or secure their health?

More explains that their “bodies are vigorous and lively; and though they are but of a middle stature, and have neither the fruit fullest soil nor the purest air in the world; yet they fortify themselves so well, by their temperate course of life.” (More, p. 119) More’s Utopia is though not a world freed from illness: “There are hospitals in Utopia .. .every town has four hospitals, that .. .are so large that they may pass for little towns; by this means, if they had ever such a number of sick persons, they could lodge them conveniently, and at such a distance that such of them as are sick of infectious diseases may be kept so far from the rest that there can be no danger of contagion.”

The hospitals are furnished with all things that are convenient for the ease and recovery of the sick. Patients are “ looked after with such tender and watchful care, and are so constantly attended by their skilful physicians, that as none is sent to them against their will, so there is scarce one in a whole town that, if he should fall ill, would not choose rather to go thither than lie sick at home.” (More, pp. 85–86)

The medical tradition is highly respected. People know of and honor works of Hippocrates and Galen for the philosophical quality of their work. But practically medicine apparently doesn’t play any important role, as “there is no nation in the world that needs physic so little as they do.” (More, p. 121)

Medicine plays a very different and more crucial, practical role in Bacon’s utopia, the new Atlantis. Bacon was much concerned with medicine and wrote about it in several works. It is, he claimed, part of our nature to aspire to immortality, and medicine tries to achieve three ends: the prolongation of life, the restitution of youth to some degree, and the curing of disease. Medicines are used for curing of disease. The lengthening of life requires observation of diets.

Bacon advocated a kind of medical meliorism i.e., the idea that we are able to gradually improve our health condition by interfering in biological processes. He rejected classical medical ideas of the human body or the organism as a microcosmos in a constant struggle to obtain balance or harmony and supported instead a medical metaphysics of the body as a composition of – in principle – inﬁnitely manipulable parts.

Health plays an important role in More’s as well as Bacon’s versions of enlightened utopianism. Promoting and managing health is important in visions of a new humanity embodied in the two versions of Utopia. People in More’s Utopia are empowered by education and apparently able to maintain their own health. In Bacon’s New Atlantis medicine produces transhumans i.e., people who live longer and suffering less disease than “standard” human beings.

Transformative Utopianism

More’s Utopia is in an imagined future. Other enlightened utopias can be in the past (a lost paradise). But utopia can also be a projection of something which already is in the present, a country (for some at some point in history United States of America, for others The Soviet Union of Mao’s China) or particular communities assumed by some to embody visions of –if not a perfect world – at least a better world than the present. These are examples of transformative utopianism.

Enlightened utopias can be seen as a kind of thought experiment. Assuming that there is no private property, that the nations aren’t under threat from other nations, that people are ﬁt and healthy, How would people ﬂourish and live together when learning, instruction, and public lectures were crucial practices in their everyday lives?

Transformative utopianism also pictures possible futures. But instead of reasoning “if such and such,” transformative utopianism projects visions of a better world on the basis of existing conditions, tendencies, or potentialities.

There were examples of transformative utopianism also in the classical world. Plutarch had a vision of an emerging new world created by Alexander the Great. Cicero conceived of Roman expansionism as a benevolent power bringing civilization to its provinces.

While enlightened utopianism was inspired by the emergence of the modern state and the rise of secular pedagogical institutions, transformative utopianism takes more diverse forms but is typically inspired by shared human experiences of weakness or vulnerability to be overcome by communal or cosmopolitan efforts.

Some forms of transformative utopianism espouse visions of a new world order based upon political power. But other kinds of transformative utopianism articulate visions of a human uniﬁcation secured by shared human experiences and institutions that take such experiences into account.

The English poet John Donne presents in poetic form a kind of rationale for a transformative utopianism. His Devotions upon Emergent Occasions contains the now famous lines (Donne 2001, p. 446):

No man is an Iland intire of it selfe; every man

is a peece of the Continent, a part of the maine;

.. .any mans death diminishes me,

because I am involved in Mankinde.

And therefore never send to know for whom

the bell tolls; it tolls for thee.

Donne’s vision has a special relevance to discussions about medicine, health, and utopianism. He wrote his Devotions upon Emergent Occasions after having survived a serious illness. Having passed the crisis and relieved for the time being Donne hears the church bells nearby. Another person didn’t survive his or her illness. Donne is reminded of – and he reminds the readers of – death’s presence as a basic human condition.

Animals have natural instincts to heal. The dog knows the grass that recovers him. But, Donne says, humans produce themselves diseases of all sorts. Donne expresses some hope for medical progress but there is not the slightest hint of a utopian future without illness and disease. On the contrary, vulnerability and shortness of life is a basic human condition. Human solidarity is a reasonable response.

The context of Donne’s meditations is Christian. But he articulates ideas of solidarity and shared humanity which have roots in earlier cultural and philosophical traditions (as Stoicism) and which is central to socialist thinking and practice in the nineteenth and twentieth century.

Ernest Hemmingway (1899–1961) quoted Donne in the opening of his novel For Whom the Bells Tolls. He didn’t, however, commit himself to a Christian understanding of solidarity. For Hemmingway solidarity is expressed by activists in a collective political practice as a response to suffering and social and political humiliation.

Utopianism And Different Attitudes To Medicine

John Donne wrote his Devotions just a few years before Bacon wrote New Atlantis. Bacon and Donne’s utopianism express completely different attitudes to medicine. Donne repeats classical medical ideals of modesty in our expectations to medicine. The doctor may support the recuperative powers of nature but he will never be the master of illness and health. Bacon, on the contrary, espouses ideas of medical omnipotence. By using experimental methods medicine would, he believed, develop cures for our diseases and secure – in principle unlimited – prolongation of the individual human being’s life on earth. These two perspectives on medicine have been alive in medicine, in lay discussions about medicine and health and in health politics now for almost 400 years. Ideas of medical omnipotence are alive in transhumanism (a movement advocating use of technologies to enhance our physical and intellectual capacities). Leading ﬁgures in clinical epidemiology, as Archie Cochrane, one of the founding fathers of evidence-based medicine, warned against growing medical optimism in the 1960s and 1970s. Based upon his own experience as a doctor for prisoners of war during the Second World War and on his epidemiological research, he defended the classical idea of medicine as a practice supporting the recuperative powers of nature.

The National Health Service (NHS) as scrutinized by Cochrane was an – at least partly – unsuccessful enlightened utopia. Its architects and managers had relied all too much on specialized medicine. He advocated more support to old and disabled people. His critique of the NHS in the beginning of the 1970s can be read as a plea for a transformative utopianism embodying ideals of care and human solidarity (Jensen 2006).

Liberal Transformative Utopianism

Immanuel Kant was well aware that utopias are not just daydreaming and wishful thinking but products of reason that may have a real political (and according to Kant a dangerous) impact. Referring to Plato and Thomas More, Kant says that it’s sweet to imagine constitutions “corresponding to the requirements of reason.” But he warned that it’s “rash to propose them and culpable to incite the populace to abolish what presently exists” (Kant 1979, p. 167).

Kant criticized More’s utopianism but Kant’s political philosophy is itself a utopianism, a vision of a future state and world order based upon reason. Without a state ruled by law, people would live in violent competition. A nation needs laws based upon a science of rights, but Kant also sketched a cosmopolitan vision of perpetual peace between sovereign democracies placing themselves under international law.

In More’s enlightened utopia, education and instruction is the basic means to improve people’s individual and social lives. But the constitution of the imagined body politic is sketched in a very general way and it remains unclear how the learning community is to be created.

Kant points to some of the problems facing such a project (though without explicitly referring to More’s Utopia). He asks how to “expect progress toward the better.” This is, he thought, more demanding than training good citizens. In a Kantian utopia there are – as in More’s Utopia – “good men who can improve and take care of themselves.” According to Kant this will, however, not happen just by means of education of youth in the home, later in schools at various levels, and further in “intellectual and moral culture.” An educational program “has no coherence if it is not designed in accordance with a plan of the sovereign power, put into play according to the purpose of, and steadily maintained there in this plan” (Kant 1979, p. 169).

Kant is not anti-utopian but he considers the kind of enlightened utopia imagined by More unrealistic. Kant’s is much concerned with the preconditions of a state that secures citizens’ well-being and health.

It would be desirable if education “from below” would be successful, but this is hardly to be hoped for. People will feel, he says, that the costs for education of their youth should be borne by the state. The state however has not sufﬁcient money “since it uses all the money for war.” Peace is a precondition of the utopian state. But in the present world – as in the world Kant lived in – nations were at war or spent money preparing for war. In contrast, More’s Utopia is protected by the sea and without any serious threats from abroad.

International relation and threats from other nations isn’t, however, the only reason why a Morean utopia isn’t realistic from Kant’s point of view. Conﬂicts within the state between utopian ideals and peoples’ selﬁshness is another important reason.

Medical Omnipotence: A Threat To A Utopian Liberal State

In The Conﬂict of the Faculties Kant (1979) discusses the role of medicine as a profession and a science. As with law and theology, medicine belongs to the higher faculties. These are the faculties the government can use to achieve its own ends of inﬂuencing people: “ﬁrst comes the eternal well-being of each, then the civil wellbeing as a member of society, and ﬁnally his physical well-being, a long life and health” (Kant 1979, p. 31).

had a very realistic view of the role and the authority of the higher faculties, including medicine. The physician practices in accordance with reason, but he has to respect the commands of an external legislator. Since the physicians deal with people’s health this must be of great interest to the government. So, the government is entitled to supervise physicians’ practice through a Board of Health. This board should, according to Kant, be composed of practicing doctors. The medical faculty is and should, Kant claimed, be freer than those of theology or law (e.g., be free with regard to determining the content of the teaching of doctors). According to Kant, there are very good reasons for allowing medicine this special status within the state. Though medicine is an art, it is an art that is drawn directly from nature and must therefore be derived from a science of nature (Kant 1979, p. 41).

Medical power embodied in skills, judgment, experimental practices, and theories gives the physician an extraordinary power in relation to patients and society in general. Since Antiquity this power has legitimated medical paternalism. But in ’s account medical power is not only based upon scientiﬁc knowledge and rational principles. Physicians are powerful also because patients ascribe magical powers to physicians. People approach physicians as if they were soothsayers and magicians. As patients people easily forget the precepts of reason: to be moderate in our pleasures, patient in our illnesses, and rely primarily on the self-help of nature (Kant 1979, p. 51).

Kant here supports a medical utopianism based of the recuperative powers of nature. But he also supports a health care system governed by medical doctors.

Kant’s reﬂections on public education, medicine, and health care as a means to a better world were written more than 200 years ago. They are still relevant for discussions about political utopias in general and for health care utopias in particular. Education plays a growing role in health care, health promotion, and health politics.

Education has, however, to be part of a thought-out political project. It cannot just be left to individual citizens and educators, Kant claimed. Because of his belief in the inﬁrmity of human nature he did not have much faith in “progress towards the better” by individual efforts. He offered a reasonable critique of any past or future enlightened utopianism, which did not place teaching and education in the context of a state’s concrete political projects taking seriously social, organizational, and economical realities. To rely on a utopianism that ignored concrete conditions of possibility of progress would be dangerous daydreaming.

Liberal Utopianism And Health

After the French Revolution medicine and health care has become a crucial part of state politics.

The medical hegemony survived the revolution. But numerous utopian visions of health care systems as central political means to make progress toward the better have come into being ever since.

According to Hegel, the French Revolution paved the way for a realistic utopianism. Political conditions and ideals for making things better were established. Hegel (1986) has summed up his narrative of the trajectory of freedom: The Orientals didn’t know that the spirit or man as such is free in himself or herself. They only knew that one is free. The consciousness of freedom ﬁrst emerged among the Greeks and they were accordingly free; but, like the Romans, they only knew that some, and not all men as such, are free. The modern European nations (especially the Germanic nations) were, according to Hegel, the ﬁrst to realize that all men are by nature free and that freedom of spirit is man’s very essence. Social justice became a measure of a nation’s capability to promote the idea of freedom for all.

Political rights and civil rights are ways to securing freedom. But the modern liberal and democratic state didn’t secure the freedom for all, which was part of Kant and Hegel’s liberal versions of utopianism.

For centuries, there has been huge health disparities nationally and internationally. Ill health limits a person’s freedom. Liberal forms of utopianism have been invalidated by inequality in health and life expectancy between social classes and between nations and parts of the world. Visions of a healthy society or a healthy world have been among the most inﬂuential and debated forms of utopianism of the twentieth century.

The development of national health care systems within the framework of the north European Welfare State after the Second World War is one example. The English National Health Service (NHS) is the exemplar of what might be called a grand utopian project. The project embodies the vision of social rights (in particular to social right to health care) as an end point of an evolutionary process beginning with political rights, continued with the recognition of civil rights and then ﬁnally social rights.

The WHO program Health For All by the year 2000 (1981) was another utopian project partly based upon a recognition of the shortcomings of welfare state projects, or at least a utopian vision of social and institutional reorganizations of health care based upon a broader understanding of health than the medico-centered health care system of the welfare state. The program also expressed a utopian vision of health promotion by engaged citizens and communities.

Both NHS and Health For All are – if read as utopias – different from the classical enlightened utopias. They are developed and articulated as part of social-political process of transformation. The programs and projects are formed, negotiated, and brought into play by intellectuals, bureaucrats, and politicians. Both national health services modeled on NHS and WHO initiatives to promote health for all are – as classical example of enlightened utopianism – expert centered. But they are not primarily educational. They are visions of collaborative changes of practice driven by the aspirations of people. Both are based on experiences of human vulnerability and the necessity of communal practices and solidarity to face the ever-present threat of illness and death. In that respect they are twentieth-century examples of transformative utopianism.

Transformative Utopian Thinking And Hope

The German philosopher Ernst Bloch’s analyses of utopianism have provided philosophical underpinnings of transformative utopianism rooted in a trust in people’s collective capabilities and will to promote a better life. His The Principle of Hope (1995) has inﬂuenced philosophical and cultural discussions about hope and utopianism for almost half a century. Utopianism is for Bloch forms of practice. People are doing utopias when struggling to improve their lives by reﬂecting on or forming visions of a better life.

Utopian perspectives are, Bloch stresses, articulated not only in philosophical treatises, literary descriptions of ideal social organizations, or political manifests but in various cultural forms as dreams, myths, fairy tales, traveler’s tales, or alchemists’ attempts to synthesize gold. Utopias are also embodied in architecture or music.

Utopianisms embody dreams or aspirations of a better life. This human striving for change, improving or perfecting conditions of life, has an ontological grounding. The world is not something ﬁxed but undergoing constant change. The material world in which we live is unﬁnished, in a state of process. We live in a world of becoming. Our future is open, a realm of real possibility. Real possibility is different from formal possibility (i.e., an imagined future, which doesn’t contradict the laws of logic).

Bloch distinguishes between two different form of utopia: abstract and concrete utopia. Concrete utopia is characterized by anticipatory elements. It is directed towards a real possible future. Abstract utopia on the other hand is wishful thinking without a will to effect real change in the world. So, people often dream of getting more money, which would change the person’s position in the world but without changing the world. Abstract utopia is compensatory.

Abstract utopia exempliﬁed in pure wishful thinking has, Bloch stresses, discredited utopias for centuries in pragmatic, political terms as in all other terms of what is desirable. Abstract utopian thinking is led astray without contact with a real forward tendency into what is better (Bloch 1995, I, p. 145).

Concrete utopia and abstract utopia are ideal types. Concrete and abstract elements are mixed in our thinking about the future. It is therefore a task to remove abstract utopia. Bloch describes this process of extracting concrete utopia from its abstract clothing “educated hope” (“docta spes”). Educated hope is not a passive but has an act-content. It is in Bloch’s words “a militant optimism.” People are detached from a “participating, cooperative process-attitude” to their lives when dominated by contemplation.

More’s and Bacon’s enlightened utopianism (i.e., More’s vision of a possible future common wealth) are mixtures of abstract and concrete utopias. Their faith in the power of instruction and science in social improvement exempliﬁes abstract utopia but the texts embodied in social practices contributed to educating hope.

Conclusion

Utopias are texts, projects, and practices which embody ideals of a better life. Utopias are ethical enterprises. Enlightened and transformative utopianism represent two different approaches to ethics in general and to medical ethics or bioethics in particular. More is not explicit about ethical matters. But in his utopia, people are able to manage their lives without much interference from the state or fellow beings. In contemporary terms, he may be presented as an advocate of self-care or self-mastery. But his Utopia also embodies a kind of govern mentality (Foucault 2008). People do not have to be forced by the state. Through extensive teaching, instruction, and practice they have acquired the virtues of the utopian state. For Bacon, health (as absence of disease) and longevity are basic values. Bacon and More don’t develop philosophical arguments to show the validity of their basic values. The values are articulated or shown in their different utopias.

In transformative versions of utopianism, ethical values (in particular solidarity) are embodied in communities struggling to prepare or develop a better life. For Donne, it was “The Church” as a home for the vulnerable humans. For activists as Hemmingway or socialists it was local or global communities resisting the market or oppressing hegemonic powers as fascism. For Kant and Hegel, supreme ethical values would be realized in emerging global communities.

Bloch shows convincingly that utopias are expressed in many different ways: in literary, political, and other kinds of texts; in daydreams and in human activities to improve the lives of individuals, groups, or classes; and in many other ways. Hegel but also Marx inspired Bloch and Bloch probably managed to overcome shortcomings in Hegel’s thinking about utopianism. Hegel would teach us that “to be at home in the world” we have to be in some ways reconciled with the history we are part of. He thought we could achieve that by adopting his philosophy of history coming to see ourselves as small wheels in the great machinery of history governed by reason. But as said by Wenning: “To achieve this act of taking responsibility it is not sufﬁcient to provide a mere historical narrative from the vantage point of the development of reason or absolute spirit, as Hegel tends to do in his worked out system. It needs to be a meaningful narrative that is also addressed to the perspectives and the concerns of historical individuals, not the least the victims of history” (Wenning 2001, p. 18).

Wenning points to the importance of a ﬁrst person perspective in ethics. This also has a special relevance to contemporary challenges to medicine and health care. The utopian narratives built into the welfare state, WHO’s health for all, or the market are resisted by groups and individuals struggling to get their perspectives and values on illness, health, and well-being recognized within the particular health care system, the state, or by international organizations. The victims of history, referred to by Wenning, are trying to be heard and sometimes are given a voice in contemporary discussion and negotiations about medicine and health care. New forms of utopianism are emerging; utopianisms embodying vision of user – inﬂuence and deliberative democracy as minority groups, oppressed groups, or weak groups attempt to create new social imageries inspired by but also different from utopias of the past.

Adriana Petryna describes examples of resistance to a “market driven medicine, neoliberal state reforms, and human rights discourses” where citizens “are reduced to their own private hyper individualized skirmishes for treatment access” (Petryna 2009, p. 198). Local initiatives in, for example, Brazil are “informed by a continued commitment to the scientiﬁc method, combined with a systemic critique of the political economy of pharmaceuticals as it plays out locally and a desire to empower public institutions to promote individual or collective rights to health.” According to Petryna such groups focus upon the “real-life Brazilian patient” and his or her clinical circumstances that may not “correspond to those of the “ideal” or highly edited subjects of clinical trials” (Petryna 2009, p. 199).

Others have pointed to the potentials of clinical trials as a means to position patients as active participants in managing health and illness: as coproducers of health. Referring to his own research experience, Tudor Hart argues that participation in trials may have huge educational potential for communities and can become “mass education in the nature of scientiﬁc reasoning and evidence.” According to Hart, patients can become active participating subjects who are fully informed and included in “discussions of trial design and its underlying logic” (Hart 2006, p. 263).

Medical hegemony has been challenged over the last 30 years. But in various contexts, e.g., in clinical research, citizens are still often positioned as passive subjects. It is difﬁcult to change paternalistic attitudes and practices, especially when such practices are revitalized by scientiﬁc arguments. Petryna and Tudor Hart provide examples of new emerging forms of transformative utopianism positioning citizens in general and patients in particular as active participating subjects in social transformation aiming at securing health for all.

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