The empowered patient on a historical-rhetorical model: 19th-century patent-medicine ads and the 21st-century health subject.

The contemporary health subject, often described as a new, empowered patient, is not simply a character in a story of progress toward knowledge and power, away from credulity and passivity. Before the 20th century, and the assertion of a medical system that became frankly paternalistic, laypeople adjudicated on many matters of illness and its treatments. That is, 18th- and 19th-century health subjects were empowered too, and studying them, especially as consumers of health products, helps us develop a more nuanced account of our current medico-commercial selves. Comparing historical advertisements for "patent medicines" and contemporary direct-to-consumer ads for prescription pharmaceuticals, this essay contributes to such an account. It identifies strategies that drug marketers have deployed over centuries to persuade consumers to buy their products, and it tracks a rhetoric of interpellation in advertisements that not only address but also constitute health subjects. The goal of the analysis is to increase alertness to our own susceptibilities to pharmaceutical ads and adjacent rhetorics of health and illness.

Sex, drugs, and rhetoric: The case of flibanserin for 'female sexual dysfunction'.

In August, 2015, the US Food and Drug Administration approved Addyi (flibanserin) for the treatment of Hypoactive Sexual Desire Disorder in premenopausal women. Ten months before that, the FDA had held a Patient-Focused Drug Development Public Meeting to address the 'unmet need' for a pharmaceutical to treat that condition. I attended that meeting as a rhetorical observer. This essay is an account of persuasive strategies used on, and then by, the FDA, as it considered approving a drug that was not convincingly either safe or effective. The essay turns on three texts: the 'Even the Score' pro-drug campaign that informed the patient-focused meeting, the text of the meeting itself, and the FDA's own published report of the event. I describe how a pharmaceutical company (Sprout, then owners of flibanserin) recruited, and then ventriloquized, both health professionals and members of the public to pressure the FDA to approve a sex drug for women - claiming that not to do so was evidence of sexism. I argue, with rhetorical evidence, that the case for approving flibanserin had already been won before Sprout submitted its application.

The sexualization of the medical.

The medicalization of sex is part of an already-in-place discursive problem that can be illuminated by looking at efforts to sexualize the medical. "Erectile dysfunction," "female sexual dysfunction," and their real and imagined pharmacopia, do not constitute the medicalization of sex; they are effects of sex already having been-to borrow a term from Peter Conrad ( 1992 )-healthicized. The equation of sex and health, as cultural common sense, has made health seem like the natural discourse for thinking about sex in the first place. Reversing the terms of this special issue, and using the methodology of rhetorical analysis, this article looks at the person with cancer as a sexualized subject-someone whose health is represented as intimately tied to his or her sex life. It suggests that, in public discourse-and notably in movies and on television-sex is the comic ending of the illness narrative. In light of this narrative move, the ability to have good sex joins the ability to be positive and cheerful as a (Western) cultural imperative of illness experience, in general, and cancer experience, in particular. Public representations of illness virtues often fail, then, to answer realistically the compelling question, "How shall I be ill?"

Naming migraine and those who have it.

Medical language has implications for both public perception of and institutional responses to illness. A consensus panel of physicians, academics, advocates, and patients with diverse experiences and knowledge about migraine considered 3 questions: (1) What is migraine: an illness, disease, syndrome, condition, disorder, or susceptibility? (2) What ought we call someone with migraine? (3) What should we not call someone with migraine? Although consensus was not reached, the responses were summarized and analyzed quantitatively and qualitatively. Panelists participated in writing and editing the paper. The panelists agreed that "migraine," not "migraine headache," was generally preferable, that migraine met the dictionary definition for each candidate moniker, terms with psychiatric valence should be avoided, and "sufferer" should be avoided except in very limited circumstances. Overall, while there was no consensus, "disease" was the preferred term in the most situations, and illness the least preferred. Panelists disagreed strongly whether one ought to use the term "migraineur" at all or if "person with migraine" was preferable. Panelists drew upon a variety of principles when considering language choices, including the extent to which candidate monikers could be defended using biomedical evidence, the cultural meaning of the proposed term, and the context within which the term would be used. Panelists strove to balance the need for terms to describe the best science on migraine, with the desire to choose language that would emphasize the credibility of migraine. The wide range of symptoms of migraine and its diverse effects may require considerable elasticity of language.

"Compliance" to "concordance": a critical view.

Advocates of "concordance" describe it as a new model of shared decision-making between physicians and patients based on a partnership of equals. "Concordance" is meant to make obsolete the notion of "compliance," in which patients are seen as, ideally, following doctors' orders. This essay offers a critical view of concordance, arguing that the literature itself on concordance, including materials at the web site of Medicines Partnership, the implementation arm in Great Britain of the concordance model, is full of contradiction; concordance, in fact, harbors an ideology of compliance. The essay suggests that an improvement in patient medication use will more likely come from a frank consideration of the relation of compliance issues and commercial ones, and that a key question across domains is, "how are patients/health agents/consumers persuaded to acquire certain drugs and take them as directed?"

lIlness as argumentation: a prolegomenon to the rhetorical study of contestable complaints.

The resources of rhetorical theory, the classical theory of persuasion, can be marshaled to help physicians evaluate patient complaints for which there is no corresponding objective evidence and which rely, therefore, on the persuasiveness of patients to be taken seriously (contestable complaints). An appropriate focus for the evaluation of such complaints is argumentation itself: what, in the absence of objective evidence of disease, counts as a good argument for a patient to be eligible for medical attention? How do patients convince physicians that they are ill and in need of care - and, conversely, how do physicians convince patients, when the need arises, that they are well and not good candidates for medical intervention? Two rhetorical concepts are especially productive for the analysis of argumentation. One is kairos, the Sophistic notion of contingency, and the other is pisteis, the Aristotelian catalogue of persuasive appeals. A focus on types of arguments directs attention away from types of patients (difficult, suspect, malingering and so on), and provides a more neutral means of judging claims to illness.