Social Science & Medicine 79 (2013) 40e47

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Social Science & Medicine

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Medicalisation or customisation? Sleep, enterprise and enhancement in the 24/7

society
Simon J. Williams a, Catherine M. Coveney a, Jonathan Gabe b, *
a
Department of Sociology, University of Warwick, Coventry CV4 7AL, UK
b
Centre for Criminology and Sociology, Royal Holloway, University of London, Egham, Surrey TW20 OEX, UK

a r t i c l e i n f o a b s t r a c t

Article history: This paper extends and problematises recent sociological research on the medicalisation of sleep,
Available online 13 August 2012 focussing on trends and transformations in the prospective ‘customisation’ of sleep in the 24/7 society.
What exactly does customisation mean in this context; how does it relate to the medicalisation of sleep;
Keywords: and how salient or significant are these trends to date in the 24/7 society? These are the key questions
Sleep this paper seeks to address, taking workplace napping and wakefulness promoting drugs amongst the
Health
‘healthy’ as our comparative case studies. Both we argue, despite their apparent differences and
Biomedicalisation
embryonic status to date, provide alternative routes to broadly similar ends. Namely they customise our
Customisation
Workplace napping
sleep patterns and practices to fit around the escalating temporal demands of daily life, thereby helping
Modafinil remedy the increasing misalignment between biological and social time. Each, moreover, seeks to
Pharmaceuticals improve or optimise safety, productivity and performance in late modern society, where alertness is
Biopolitics prized, sleepiness is problematised and vigilance is valorised. The paper concludes with some further
reflections on these matters, including relations between the biomedicalisation and the customisation of
sleep and a research agenda on the biopolitics of sleep and wakefulness.
Ó 2012 Elsevier Ltd. All rights reserved.

Introduction between these two prospective sleep management strategies in

A key strand of recent sociological scholarship on sleep concerns
the degree to which it provides another prime example of the
medicalisation of society. For all its promise as a rich vein of
sociological research, further pertinent questions arise here
regarding other forms of sleep ‘management’ in late modern
society, which potentially problematise or qualify arguments about
the medicalisation of sleep and suggest the need for further eluci-
dation and conceptual clarification.
It is in this context therefore, as a small contribution to this
broader enterprise, that this paper is located. In particular we ask
whether there are any significant signs that sleep is being ‘cus-
tomised’ in the so-called 24/7 society and, if so, in what ways and to
what degree? We also seek to reflect on where this leaves us in
terms of current debates on the medicalisation of sleep and asso-
ciated research agendas in this newly emerging field of sociological
inquiry. More specifically we ask, taking workplace napping and
wakefulness promoting drugs amongst the ‘healthy’ as our two
case studies, what comparisons and contrasts may be drawn
* Corresponding author.
E-mail address: s.j.williams@warwick.ac.uk (S.J. Williams).
late modern society; how salient and significant are they to date
and where, precisely, do they fit in relation to these current debates
on the medicalisation of sleep and society?
The paper builds in new ways on both our own previous
sociological work on the medicalisation and politics of sleep
(Williams, 2011, 2005; Williams, Seale, Boden, Lowe, & Steinberg,
2008) and other recent research on medico-managerial agendas
regarding sleep (Brown, 2004; Hancock, Williams, & Boden, 2009)
and the changing fate and fortunes of practices like the workplace
nap in a global context (Baxter & Kroll-Smith, 2005). Whilst
important work has also recently been done on sleeping cultures in
Asia and the West, both past and present (cf. Brunt & Steger, 2008;
Steger, 2003), the main focus in this paper, given our concerns and
expertise, is primarily on the latter, particularly the North American
and Northern European context in this latest phase of so-called
‘late’, ‘fast’, ‘flexible’ or ‘post-Fordist’ capitalism (Harvey, 1989).
Our ‘data’ come in a variety of forms, including both existing
relevant studies and other documentary sources bearing on these
themes. Due to the limited nature of the data that are at our
disposal, however, our discussion of the workplace nap focuses
mainly on ‘upstream’ issues whereas our discussion of wakefulness
promoting drugs also draws on data from interviews and surveys
about the prospective use and meaning of such drugs in everyday

0277-9536/$ e see front matter Ó 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.socscimed.2012.07.017
 S.J. Williams et al. / Social Science & Medicine 79 (2013) 40e47
life (i.e. more ‘downstream’ issues). As for the ‘novelty’ of the trends
we document, on the one hand of course they may legitimately be
considered part and parcel of a long history of attempts to manage
or modify our sleep, with or without the aid of drugs. On the other
hand, we suggest they signal significant, if embryonic, attempts to
optimise or perhaps eventually optionalise sleep in late modern
society.
All this however begs prior questions regarding the very
‘problematisation’ of sleep today, including medicalising trends and
associated issues to do with framing sleep through the health, risk
and lifestyles nexus. We start, therefore, with a brief sketch of these
trends as a backdrop to the themes and issues that follow in the
main part of the paper, where workplace napping and wakefulness
promoting drugs are compared and contrasted.
Problematisation/medicalisation? Sleep, health and risk
Professional and public concern is increasingly voiced about the
relentless nature of life today where sleep is all too frequently
sacrificed in favour of other demands, desires or dictates. Sleep
problems, it is claimed, are endemic in contemporary society given
the transition to a 24/7 global age and the advent of an on-line
digital culture to keep us from our beds, or leave us tossing and
turning in them, in a wired-awake world of work and worries. It is
not our intention to rehearse these claims, or the evidence upon
which they are based, again here e see, for example Martin (2002)
and Dement and Vaughan (1999). A number of key points none-
theless can be made as a backdrop to the themes and issues that
follow.
First, despite this growing emphasis on the problems of sleep in
professional and popular culture, debates continue as to the precise
nature and extent of any such problems, particularly the notion that
we are now a ‘chronically sleep deprived’ society. Horne (2007), for
example, questions whether short sleep (6 h or less hours per
diurnal day) does harm health and draws attention to the fact that
we have very little historical comparative data about the quality or
quantity of sleep people had on average through different time
periods.
Second, these contemporary sleep ‘problems’ are now increas-
ingly framed and filtered through expert discourses of risk
regarding the public as well as the personal costs and consequences
of poor sleep for society. In terms of individual health, for example,
getting short sleep on a regular basis has been associated with an
increased risk of developing a variety of serious health problems,
such as obesity and cancer (Thompson et al., 2011). Sleep depri-
vation is also thought to lead to impaired cognitive performance in
the workplace, decreased productivity and an increase in accidents
and errors (Alhola & Polo-Kantola, 2007; Barger, Cade, Ayas et al,
2005), thereby highlighting the multiple costs and consequences
of poor sleep for society.
It is in this context that questions concerning the medicalisation
of sleep have come to the fore in recent years: a process, which
denotes the expansion of medical jurisdiction and control over
sleep, conceptually in terms of using medical vocabulary to
describe sleep ‘problems’, institutionally through the adoption of
a medical approach to treat these problems and interactionally
when the problem is discussed between patient and clinician (cf.
Conrad, 1992).
The medicalisation of sleep nonetheless is far from complete.
Rather, it is a complex, contested, partial process in which some
aspects of sleep are becoming more medicalised than others. Sleep,
in other words, is medicalised to varying degrees depending on the
particular dimension or problem in question. Insomnia, for
example, has proved a far more problematic condition to medicalise
over the years than other sleep problems or disorders with a more
41
tangible physiological or neurological basis, such as obstructive
sleep apnoea (OSA), narcolepsy or restless legs syndrome
(Matteson-Rusby, Pigeon, Gehrman, & Perlis, 2010). Even so-called
‘shift work sleep disorder’ (SWSD), which may seem like an
obvious case of the medicalisation of a social problem, remains
a contested diagnostic category (Coveney, 2010). To the extent,
moreover, that sleep medicine is still in its relative infancy, and
many sleep ‘problems’ apparently remain undiagnosed and unde-
tected due to a lack of basic training in sleep medicine and a lack of
awareness amongst the general public (Dement & Vaughan, 1999),
this further underlines the partial nature and status of sleep today as
a medicalised matter (Williams, 2011).
The changing drivers of these medicalisation processes (Conrad,
2007) are also important to consider in this context. Key factors
here include the aforementioned growth of sleep medicine in
recent decades; the wider efforts of sleep experts within and
beyond sleep medicine to raise the profile of sleep as a significant
public health and safety issue or ‘matter of concern’ (Dement &
Vaughan, 1999; Wolf-Meyer, 2008); industry interests in the sleep
drugs, devices and diagnostics markets (Alexander, 2009); multiple
media framings of sleep matters over time (Seale, Boden, Williams,
Lowe, & Steinberg, 2007; Williams et al., 2008); and finally, the
associated growth of more active forms of consumerism and citi-
zenship, personhood and patienthood (Rose, 2007; Williams, 2011).
It is also clear that many of these processes extend far beyond
anything conventionally ‘medical’ or ‘medicalised’ to encompass
the multiple relationships now evident between sleep, health and
lifestyle in popular culture and everyday life. This, in turn, is closely
bound up not simply with the aforementioned discourses of risk
but also associated notions of responsibility. In late modern society
we are all increasingly encouraged, as active, responsible citizens,
to manage our sleep wisely given the multiple risks to health and
safety, both public and personal, that poor sleep is said to pose. It is
not simply a matter of attempting to medicalise sleep problems, but
of the promise of good sleep for health and well-being, if not
happiness, wisdom and virtue.
It is at this point therefore that further questions arise around
transformations or potential transformations regarding sleep in the
24/7 society. What does customisation mean in this context? How
does it relate to the medicalisation of sleep? And how significant
are these trends to date? It is to these questions that we now turn.
Transformation and optimisation? Sleep, safety and
performance
Our contention is that sleep today is not simply being medi-
calised but customised in various ways that problematise existing
notions of normality and abnormality, health and illness. Custom-
isation, for our purposes, denotes the ways in which sleep is being
reframed or reconfigured in order to improve, enhance or optimise
not simply health but safety, productivity and performance in late
modern society.1 Customisation, in this respect, aims to reduce the
tension, or increase the ‘fit’, between our bodily need for sleep and
our age old chronobiological rhythms that govern it (i.e. our bio-
logical or circadian clocks) and the escalating around-the-clock
demands and dictates of social time in the 24/7 society. Whilst
customisation moreover implies various individualised, personal-
ised or tailor-made options or solutions, it is the ‘shifting,
1
The customisation of sleep within the military is another important case in
point; particularly as far as the relays between medicalisation, militarisation and
customisation are concerned. A full consideration of these matters is beyond the
scope of the present paper. See Williams (2011) and Ben-Ari (2003) for early forays
along these lines.
42 S.J. Williams et al. / Social Science & Medicine 79 (2013) 40e47
reshaping, reconstituting, and ultimately transforming of bodies for
varying purposes’ (Clarke, Mamo, Fishman, Shim, & Fosket, 2003;
Clarke, Mamo, Fosket, Fishman, & Shim, 2010: 181) that concerns us
most in what follows: forms of augmentation, enhancement or
optimisation that is to say (cf. Greely et al., 2008; Miller & Wilsdon,
2006; Rose, 2007).
To speak of the customisation of sleep in this way, as noted
earlier, is not to deny the long history of ways in which sleep has
been managed, modified or medicated through the centuries. It is
nonetheless to suggest that something significant is happening
today given the particular configurations of expertise, enterprise
and enhancement at stake, even if the forms of intervention
entailed are not entirely new. Such inventions have the potential to
customise or reconfigure the ‘vital normativities’ of the sleeping/
waking body or ‘life itself’ (cf. Rose, 2007).
In the following section of the paper, therefore, we draw on
a range of scientific, social science and popular sources to discuss
two possible examples of these ‘customising’ trends and trans-
formations of sleep today: the workplace nap and wakefulness
promoting drugs.
Taking a nap; sleeping on the job?
Our working lives have a huge impact on when, for how long
and how well we sleep. For instance, recent studies have found that
long work hours (more than 48 h per week) are associated with
short sleep durations (less than 6.5 h per night), particularly for
women workers (Bryan, 2011), and that male workers actively
negotiate the amount of time they spend sleeping in relation to the
amount of work they have to get done the next day (Meadows,
Arber, Venn, & Hislop, 2008). Sleep, it seems, is something which
is often cut back on, being sacrificed or dismissed in order to pri-
oritise the demands of our waking lives. Sleep loss and fatigue
indeed are prevalent problems in the modern workforce, particu-
larly as long work hours and shift work become more common
again (Stoller, Papp, Aikens, Erokwu, & Strohl, 2009).
Challenges to popular cultural idioms and ideas about sleep (for
example, that ‘sleep is for wimps’, a sign of ‘laziness’ or ‘a waste of
time’ in our busy lives) are becoming increasingly evident from
within sleep science and sleep medicine communities. Consider, for
example, an interview in the Harvard Business Review (2006) with
Charles A. Czeisler e professor of sleep medicine at Harvard
Medical School, one of the world’s leading authorities on human
sleep cycles and circadian rhythms e which is tellingly entitled
‘Sleep Deficit: The Performance Killer.’ Czeisler’s message to
corporate leaders is ‘simple’: ‘If you want to raise performance e
both your own and your organization’s e you need to pay attention
to this fundamental biological issue’ (2006: 54; our emphasis).
A ‘good sleep policy’, Czeisler continues, is a:
‘.smart business strategy. People think they’re saving time and
being more productive by not sleeping, but in fact they’re
cutting their productivity drastically. Someone who has
adequate sleep doesn’t nod off in an important meeting with
a customer. She can pay attention to her task for longer periods
of time and bring her whole intelligence to bear on the project at
hand.’ (2006: 58, our emphasis)
Whilst many strategies are used in the workplace to counter the
effects of sleep loss and manage fatigue e from the consumption of
caffeine to promote wakefulness to the use of light boxes to realign
ones circadian clock (Cf. Arendt, 2010; Smith, Fogg, & Eastman,
2010; Stoller et al., 2009) e sleep is often championed by those
within the expert community as being the ultimate performance
enhancer (Ferguson, Paech, Dorrian, Roach, & Jay, 2011; Mednick,
Cai, Kanady, & Drummond, 2008), as well as being essential for
general health and wellbeing. Trading on a workplace sleep ‘deficit’,
from this viewpoint, is far from being a smart move, if you want to
get the best from your workforce that is.
Research into how workers can most profitably adjust or
customise their sleep patterns in order to adapt to the demands of
their work schedule is a burgeoning field of scientific inquiry
(Arendt, 2010; Horne, 2011; Smith et al., 2010; Stoller et al., 2009). It
is in this context that the workplace nap comes to the fore as a short
or ultra-short solution to these modern day dilemmas: a potentially
powerful if not a perfectly ‘natural’ means of reconciling biological
and social, corporeal and corporate, individual and institutional
demands in the interests of all parties.
A nap can be defined as a ‘planned period of sleep’ (Venn &
Arber, 2011: 201), as opposed to dozing or drifting or nodding off
unintentionally in the workplace, which would of course be a cause
for concern in any work environment. Workplace napping also
marks a break with other forms of napping practised outside the
workplace, be it for leisure, pleasure or simply the product of
boredom, sickness, (early) childhood or (old) age.
It has recently been claimed that taking a short nap (of less than
20 min) in length is as effective a strategy to maintain alertness
throughout the day as is extending night time sleep by one hour
(Horne, 2011). Numerous other studies have found that napping
improves aspects of cognitive performance (Lovato & Lack, 2010;
Mednick et al., 2002; Stickgold, 2006; Stickgold & Walker, 2005)
and suggest that taking a nap may be as effective as a full night of
sleep in relation to the ‘sleep dependent’ learning of new tasks
(Mednick, Nakayama, & Stickgold, 2003). Recent studies also point
towards the ‘cost-effectiveness’ (Horne, 2011: 11) of ‘customising’
(in our terms) one’s sleep patterns through napping as it not only
maintains alertness and improves performance during the day
(Horne, 2011) but means that less sleep is then needed at night.
These claims are echoed and amplified through a growing list of
popular science books, written by sleep experts, bearing such titles
as: Power Sleep (Maas, 1999); Sleep for Success (Maas & Robbins,
2010); The Art of Napping at Work (Anthony & Anthony, 2001);
and Why We Nap? (Stampi, 1992). Take Maas’s book Sleep for
Success, for example, where he asks ‘What’s so “macho” about not
sleeping?’ before proceeding in the remainder of the book to
address a wide range of issues from new findings on sleep depri-
vation e dubbed ‘the silent killer’ e and new discoveries in the
science of sleep, to chapters on ‘sure fire strategies to sleep for
success’, ‘what’s your naptitude?’, ‘surviving shift work’ plus
a ‘sleep for success performance log’ in the appendix. Consider also,
the following extract from Anthony and Anthony’s book The Art of
Napping. To nap or not to nap is no longer the question, they boldly
proclaim:
As we go into the future, the question will be when and where to
nap, not whether to nap.We are finally waking up to the life-
enhancing value of sleep.In the 21st century changes in the
workplace can ensure that we overcome the virus destroying
the quality of our work and our lives. The napping community
will continue to open employers’ eyes to the merits of napping
(1999: 125)
It is recognised that these claims and conclusions need to be
accepted cautiously until more comprehensive research pro-
grammes are conducted (Lovato & Lack, 2010). However, it is at the
same time evident that a growing community of sleep science and
medical experts are beginning to reframe sleep e and its ‘cus-
tomisation’ through napping e as a natural ally to workplace
productivity, contemporary work culture and work ethics.
A key factor here is the transformation of napping into an offi-
cially approved or sanctioned practice in the workplace, either at
break-time or on-the-job during work-time proper. Whilst there are
 S.J. Williams et al. / Social Science & Medicine 79 (2013) 40e47
several professions and occupational roles in which napping is
already officially sanctioned, for instance doctors who are on call,
such a transformation across the workforce appears to be somewhat
embryonic, with little systematic data available to draw on as yet.
A notable exception comes from a recent Sleep Foundation
(NSF) poll on ‘Sleep, performance and the workplace’ (2008) con-
ducted in the US. The survey reports that around one-third of
respondents said napping during breaks was allowed in their place
of work. Of those respondents who worked in places where
napping was not sanctioned, 26 percent reported that they would
take naps at work if their employer allowed it. However, only 10
percent of respondents said that they had ever napped at work. The
practicalities of sleeping in the workplace, therefore, may mean
that napping is not always possible or a practical solution to sleep
loss (Stoller et al., 2009).
The very type and purpose of napping may also vary from sector
to sector, occupation to occupation, as well a cross-culturally and
globally. Baxter and Kroll-Smith (2005), for example, draw a further
potentially useful distinction between: (i) lower-status shift-
workers and other workers in ‘time-sensitive’, ‘safety-critical’
occupations such as the transportation industry, where prescribed
or regulated ‘break-time’ naps may be the commonest type of
napping practised, and; (ii) those working in typically high status
occupations geared to more ‘cerebral’, ‘intense’, ‘project-driven’
labour, where ‘work-time’ napping may be favoured, at the
employee’s discretion, due to more autonomous, flexible, ‘trust-
based’ employment policies and practices. It is also somewhat ironic,
as Baxter and Kroll-Smith (2005) note, that the decline of the midday
nap in countries such as China (i.e. the Xiuixi) ‘is considered part of
the price of modernisation while its emergence in the post-Fordist
West is treated by many as an improvement in the quality of work
life that, if managed correctly, also increases productivity’ (2005: 49)
(see also Steger and Brunt 2003, especially the chapter by Li, 2003).
Mention should also be made, at this point, of other expert-
based consultancy firms and associated commercial ventures
which specialise in alertness or fatigue management in the modern
day workplace and around-the-clock operations and industries.
Alertness Solutions (2012), for example, whose motto on its web-
site is ‘translating the science of fatigue into “practical, effective,
powerful, impactful, customized” (these words alternate on screen)
solutions that improve safety and performance’ and span industries
such as ‘transportation’, ‘energy and mining’, ‘health care’ and
‘public safety, military and government’. ‘CIRCADIANÒ: 24/7 work-
place solutions’ also, according to its website (Circadian, 2012),
provides:
‘consulting, training, technology and information to solve the
challenges of the 24/7 workforce, including:
 Optimized Shift Schedules
 Fatigue Risk Management Systems
 Shift Worker Training
 Shiftwork Publications’
‘Over half the Fortune 500’, we are told, ‘rely on CIRCADIANÒ for
shift schedules, worker fatigue, and workforce training solutions
for their global 24/7 shift work operations’ (Circadian, 2012).
Finally, why not take a nap in a dedicated ‘sleep pod’ or ‘Ener-
gyPod’ which, according to the provider of the latter, MetroNaps, are
now installed in ‘offices, hospitals, universities and fitness centers
in dozens of countries across four continents’ (MetroNaps, 2012).
Whether or not these are quite the enlightened, flexible, sleep-
friendly or worker-friendly policies and practices they appear to be
however is a matter of debate.
They certainly signal attempts to change negative attitudes and
practices regarding sleep within the modern day workplace, if not
43
‘normalise’ napping as an acceptable rather than a marginal or
maverick practice in some organisations. They also express expert
led agendas, feeding sleep science into modern day work culture
(Brown, 2004; Hancock et al., 2009), either as part and parcel of
official health and safety programmes or in the service of other more
general productivity and performance drives, thereby enhancing
contemporary work ethics still further in the 24/7 society.
To the extent, moreover, that developments of this kind are also
profitable in commercial terms, through consultancy firms, popular
self-help books and the like, they also feed into the wider ‘sleep
industry’ which is busy ‘capitalising’ on our sleep, quite literally, day
and night (see for example Brown, 2004; MooAllem, 2007; Williams,
2005; Williams & Boden, 2004). Perhaps most importantly, as Baxter
and Kroll-Smith (2005) remind us, however embryonic these trends
and transformations may be, initiatives of this kind amount to
a further blurring of the boundaries between home and work, public
and private time, thereby turning short or ‘ultra-short’ sleep (qua
napping) not simply into a ‘productive act’ but a ‘regulated time-
space behaviour’ in this latest phase of so-called ‘flexible’ capi-
talism (Hancock et al., 2009). Thus, the customisation of sleep
through such activities might be seen as illustrating corporate
attempts to ‘reconstitute the dormant body as a site of organization
and managerial intervention’ (Hancock, 2008; 411).
To date, to repeat, these trends remain embryonic, with varia-
tions in the very type and purpose of napping from sector to sector
and occupation to occupation. Furthermore, potentially significant
gender, age, period and cohort effects need to be considered in
future research. Resistance to any such trends, expert backed or
otherwise, remains a potentially significant issue, not least through
the aforementioned neglect or negation of sleep matters both
inside and outside the late modern workplace.
Whilst the widespread adoption of such policies and practices
therefore seems unlikely, in the near future at least, this does not
negate our argument as to their ‘customised’ status to date; niche
strategies, in effect, by sector and occupation, which may or may
not become more widespread or ‘normalised’ as the 24/7 society
advances.
Next we turn to another form of potentially customising sleep in
the guise of wakefulness promoting drugs.
Popping a pill; waking up to modafinil?
Within medicine, a number of techniques and technologies are
currently employed to aid sleep management, depending upon the
sleep disorder in question. For example, patients with Obstructive
Sleep Apnoea syndrome are given a mechanical device and face-
mask to control airflow and help them achieve better quality sleep
throughout the night, with the goal of eliminating daytime sleep-
iness. Insomnia patients may be prescribed hypnotics to aid sleep
onset or in some cases, prescribed a course of cognitive behavioural
therapy to help them retrain their sleep habits. Narcolepsy patients
are often prescribed alertness promoting medication to help them
stay awake during the daytime. Outside the medical sphere, those
of us without clinical sleep problems can also turn to a variety of
other foodstuffs and over the counter remedies to aid sleep onset or
boost alert wakefulness at socially desirable times. All of these, in
one sense or another, could be considered methods to try and alter,
adjust if not ‘customise’ our sleep patterns in the 24/7 society. In the
following section, however, we consider one of these techniques in
more depth e the use of pharmaceutical drugs ‘beyond’ the surgery
or clinic to promote alert wakefulness and cognitive functioning
amongst the otherwise ‘healthy’.
This is a pertinent and timely issue to discuss as over recent
years the availability of new types of wakefulness promoting drugs
e that not only promote a state of prolonged wakefulness but also
44 S.J. Williams et al. / Social Science & Medicine 79 (2013) 40e47
may enhance or improve cognitive function in the user e has
fuelled an extensive and ongoing ethical debate (e.g. Chan & Harris,
2006; Farah, 2005; Greely et al., 2008; Hyman, 2006; Wolpe, 2002).
Particular concerns arise around whether healthy adults should be
allowed to have access to this type of pharmaceutical technology,
either now or in the future, in order to stave off sleep, promote
alertness and in so doing, also enhance their cognitive abilities.
An exemplar is the drug modafinil, which is currently available
as a treatment for narcolepsy in the UK, and has also been tested for
possible ‘enhancing effects’ in a variety of ‘healthy’ populations.
Studies have shown that as well as improving feelings of increased
alertness and maintaining wakefulness in those who have sleep
disorders or who are sleep deprived (Caldwell, Caldwell, Smith,
Alvarado, & Heintz, 2004), use of the drug can provide a variety
of moderate cognitive benefits to those without illness, including
improving attention, memory and executive functions (Gore, Webb,
& Hermes, 2010; Müller, Steffenhagen, Regenthal, & Bublak, 2004;
Pigeau et al., 1995; Repantis, Schlattmann, Laisney, & Heuser, 2010;
Turner et al., 2003).
The availability of this type of drug has led to much debate and
speculation that there will be a significant lifestyle or recreational
market for modafinil as both a wakefulness promoting drug and
a cognition enhancer, in all areas of social life. Those who it is
claimed may benefit range from people who work the night shift to
ambitious professionals trying to pack more work into a day and
students who want to pull all-nighters (see Cheshire for example
(2008) on the pros and cons of the ‘pharmaceutically enhanced
physician’). Embedded within this type of pill, then, is the promise
of a pharmaceutical future where we can remove the constraints of
our biological bodies and, in effect, choose when to be awake and
when to sleep. The availability of pharmaceutical technologies such
as modafinil, seemingly then, fit as another way in which we can
further control, optimise, customise or perhaps even optionalise our
sleep, by providing a way for us to override our biological rhythms
of sleep and wakefulness.
The vision that we may soon be able to choose to pharmaceu-
tically customise our sleepewake cycles ties into wider discourses
and debates around the increasing prevalence of sleep deprivation
in late modern societies. For instance, studies have found that short
sleep is commonplace in contemporary society and, as noted above,
the amount of sleep people get is often tied to and influenced by
their lifestyle and social situation, including family commitments,
work hours and even whether they sleep with a partner or not
(Arber & Meadows, 2011; Bryan, 2011; Chatzitheochari & Arber,
2009; Williams, Meadows, & Arber, 2010). It has been claimed
that as a society we are increasingly living out of synchrony with
the biological rhythms for sleep and wakefulness that are pro-
grammed into our bodies (termed ‘social jet lag’ in the scientific
literature, e.g. Wittman, Dinich, Merrow, & Roenneberg, 2006) and
that this can affect our health and psychological wellbeing. Phar-
maceutical technologies are then being positioned as one possible
remedy or solution to this contemporary problem.
It is however worth stepping back from the promise and hype
around these drugs to provide a note of caution. The company who
manufactures modafinil stresses that although the drug may help
sleepiness associated with a number of medical conditions, it is not
a replacement for sleep; its use may not stop all feelings of sleepiness
and levels of wakefulness might not return to a normal level
(Cephalon, 2010). In addition, the efficacy of using the substance to
improve cognitive functioning is an area of scientific debate (e.g.
Randall, Shneerson, Plaha, & File, 2002).
Despite this and although somewhat limited, there are survey
data to suggest that modafinil is already being accessed and used by
some as a way to enhance their alertness, concentration levels and
focus (Maher, 2008). However, there have been calls for a ‘reality
check’ on this count, with ethicists accused of overestimating the
prevalence of non-medical use of such prescription drugs and
normalising the idea of enhancement practices (Hall & Lucke, 2010;
Martin, Pickersgill, Coveney, & Williams, 2011; Quednow, 2010).
Clearly, more data are needed in order to assess who is actually
using these drugs and their motivations for doing so.
In a recent study Coveney (2010, 2011) interviewed prospective
users of modafinil in order to explore in more depth why people
who considered themselves to be healthy might choose to take
modafinil and how the drug might be used in two different social
domains e the workplace and the university. Wolpe argues that
‘clearly, some of the top selling drugs in the world today are being
used by patients who fit no traditional definition of pathology, yet
still see in their own functioning a deficit that these drugs address’
(2002: 382). For the most part, Coveney’s data (2010, 2011) appear
congruent with this position. Those of her respondents who re-
ported experiencing some sort of sleep deficit thought that mod-
afinil could be part of the solution for them, a way to customise
their sleepewake patterns in order to function effectively at
socially desirable times. However, she also found that the idea of
pharmacologically controlling sleep and wakefulness and aug-
menting cognitive functioning by healthy persons was met with
a high level of scepticism and ambivalence. Although her respon-
dents admitted that there was a certain allure or intrigue attached
to the idea of controlling or replacing sleep and felt tempted to try
the drug, at the same time they expressed concerns over its safety,
side effects, health risks, dependency, addiction and possible future
health problems. Thus, she found that the safety of the pharma-
ceutical technology and potential health risks associated with using
the substance were important issues in determining appropriate
roles for the drug in everyday life, problematising its use outside of
medical or at least professional authority.
This raises further issues and concerns about the customisation
of sleep through pharmaceuticals. To what extent is this really such
an alluring prospect?
Comparisons and contrasts: two sides of the same coin?
What comparisons and contrasts may be drawn then between
the workplace nap and wakefulness promoting drugs in the 24/7
society? Are they really so different, and if so in what ways? How do
these customisation strategies fit in relation to current debates on
the medicalisation of sleep and society? And, where does this leave
us in terms of the previous discussion of relations between sleep,
health and medicine today?
At first glance taking a nap and popping a pill could not be more
different: the former realised through the power of sleep, albeit
a short or ‘ultra-short’ sleep; the latter realised through the power
of drugs to keep us awake. The general thrust of the foregoing
discussion suggests otherwise however. It is not so much the
differences but the similarities between workplace napping and
wakefulness promoting drugs that are most significant for our
purposes.
Both, we have suggested, may be regarded as sleep-related
‘customisations’ of sorts which do not as such fit easily with
traditional sociological concepts and definitions of medicalisation
or the familiar polarities of normality and abnormality, health and
illness. As ‘aids’ or ‘remedies’ for daytime sleepiness, indeed, these
are in effect two different strategies for achieving the same end:
augmenting, boosting, enhancing or optimising safety, produc-
tivity, performance by remedying the apparent ‘misalignment’
between biological and social time in the 24/7 society.
At the same time some problems or tensions may also be noted
regarding the notion of customisation. To the extent, for example,
that napping is or becomes an accepted practice within the
 S.J. Williams et al. / Social Science & Medicine 79 (2013) 40e47
workplace, and to the extent that workplace napping is or becomes
not simply a recognised but a regulated practice, then the critical
issue perhaps becomes the potential ‘normalisation’ of napping
within any particular workplace setting (cf. Baxter & Kroll-Smith,
2005). Similarly, whilst the use of wakefulness promoting drugs
amongst the healthy remains a marginal practice to date, its nor-
malisation within certain contexts or sectors of society, if not more
widely, remains a possibility, albeit a distinctly unlikely one.
Instructive comparisons and contrasts may also be drawn, in this
regard, with Clarke et al.’s (2003, 2010), account of the transition from
‘medicalisation’ to ‘biomedicalisation’: the latter a term designed to
capture the increasingly multi-dimensional, multi-sited, techno-
scientific nature of biomedicine today, including trends and transi-
tions from the ‘normalisation’ of bodies to the aforementioned ‘cus-
tomisation’ of bodies. Five central processes are identified by Clarke
and colleagues in this regard, namely: ‘major political economic shifts;
a new focus on health and risk and surveillance bio-medicine; the
technoscientisation of bio-medicine; transformations of the produc-
tion, distribution, and consumption of biomedical knowledge; and
transformations of bodies and identities’ (2003: 166).
Modafinil as a biomedical technology certainly qualifies on
these counts, particularly the latter, as a case of biomedicalisation,
through its potential non-medical uses for ‘enhancement’ or
‘optimisation’ purposes which clearly includes yet extends beyond
mere ‘therapy’ or ‘health’ concerns. To the extent that these ‘non-
medical’ or ‘social’ uses amongst healthy workers helps reduce
risks of harm to health and safety, then it still clearly has ‘health
promoting’ elements, even if or when safety and performance are
the foremost concerns.
However, workplace napping is a far less simple or straightfor-
ward case of biomedicalisation. On the one hand it more or less
readily fits, given the aforementioned role which various forms of
sleep-related expertise play today in encouraging napping within
the workplace, particularly when such practices are integrated into
or tacked on to extant workplace health and safety polices and
programmes (cf. Baxter & Kroll-Smith, 2005; Brown, 2004). On the
other hand, once again, it clearly includes yet takes us beyond any
such processes. To the extent that much of this expertise stems
from sleep science rather than sleep medicine, and to the extent
that the bottom line in any such official uptake of the workplace
nap has more to do with optimising safety or performance than it
does with improving the health and well-being of employees, then
it remains at best a partial case of biomedicalisation.
Viewed in this light then, despite their apparent differences,
both workplace napping and wakefulness promoting drugs may
profitably be considered as two sides of the same coin: attempts, in
effect, through the customisation of sleep, to align or realign our
biological and social clocks not simply in the interests of enhanced
or optimised safety, productivity and performance but in ways that
potentially extend far beyond existing poles of health and illness.
This of course is not to suggest that these temporal matters of
realignment can or should be conflated or equated with these latter
Table 1
Customising sleep amongst the ‘healthy’: Comparisons and contrasts.
Workplace Wakefulness Comments
nap promoting drugs
Sleep promoting? Yes No Napping however only promotes a short or ‘ultra-short’ sleep; Modafinil moreover does not stop sleep if
users so wish
Health promoting? Partly Possibly Both are ‘preventative’ measures of sorts to counter risks to health and safety brought on by sleep deprivation
and associated cognitive impairment
(Bio)Medicalisation? Partial Yes Both fit biomedicalisation as customisation strategies, albeit to varying degrees
Optimisation? Yes Yes Both may be seen as safety/performance enhancing strategies
Politicisation? Yes Yes Part of contemporary biopolitics
45
matters of augmentation, enhancement or optimisation. Nor is it to
imply they are driven by the self-same forces. There is nonetheless,
we suggest, a close association between them in terms of the goals
or ideals they aspire to or articulate; part and parcel perhaps of
what Rose (2007), updating Weber (1974/1930), terms an ‘elective
affinity’ between a ‘contemporary somatic ethics’ and the ‘spirit of
biocapitalism’. Both nonetheless, as we have also seen, remain
contested matters to date. The workplace nap, for example, remains
controversial given that negative attitudes and values regarding
sleep still prevail in contemporary work culture. Considerable
ambivalence if not outright scepticism, as we have suggested, also
surrounds the use of wakefulness promoting drugs on anything
other than medical grounds.
A return to the question posed in the title of this paper is also
perhaps instructive at this point. Clearly, in answer to the ‘medi-
calisation vs customisation’ question, the general thrust of the
paper has been to suggest that customisation is the more apposite
or preferable term of reference for the cases under consideration.
Given customisation is closely linked to biomedicalisation,
however, the answer perhaps might equally well be framed as
biomedicalisation rather than medicalisation or customisation. To
the extent, nevertheless, that: (i) biomedicalisation is a broader
term of reference than customisation; (ii) the forms of custom-
isation discussed in this particular paper do not simply extend
beyond existing poles of health and illness but, in the case of
napping at least, are not particularly biomedicalised, then cus-
tomisation remains our concept of choice.
Customised, biomedicalised or otherwise, it also clear that these
are political matters through and through (Wolf-Meyer, 2008). To
the extent that there are important potential elements of resistance
to any such trends and transformations in society, then it is perhaps
equally important to speak here of the politicisation of sleep today
as a ‘vital’ biopolitical matter. It raises issues to do with the
governance of sleep and wakefulness in the 24/7 society in the
name of health and safety, productivity and performance, if not
enhancement or optimisation. Biopolitics, as this suggests, is
a broader term of reference than medicalisation or even potentially
biomedicalisation, denoting as it does the countless ways in which
the governance of life itself is a political matter through and
through. Biopolitics in other words, as Rose succinctly states:
.is neither delimited by the poles of illness and health, nor
focused on eliminating pathology to protect the destiny of
nations. Rather, it is concerned with our growing capacities to
control, manage, engineer, reshape, and modulate the very vital
capacities of human beings as living creatures.a politics of ‘life
itself’ (2007: 3).
The medicalisation of sleep then, from this latter stance, is
indeed only part of the story given the wider biomedicalisation and
biopolitics of sleep and wakefulness today in the 24/7 society. A
summary of these issues, both conceptually and comparatively, is
provided in Table 1.
46 S.J. Williams et al. / Social Science & Medicine 79 (2013) 40e47
Conclusion
In this paper, we have argued that sleep is not simply being
problematised or medicalised through expert-led discourses and
debates on the risks of poor sleep for society. Instead it is being
‘customised’ in the post-Fordist Western world in ways that
potentially at least, both now and in the near future, take us beyond
existing notions of normality and abnormality, health and illness, to
wider questions of safety, productivity and performance, if not
enhancement and optimisation.
Both workplace napping and wakefulness promoting drugs are
prime examples of these trends and transformations; two different
strategies in effect, of customising our sleep and optimising our
safety and performance in the 24-h society, where alertness is prized,
sleepiness is problematised, and vigilance is valorised. These trends,
to be sure, are embryonic to date, and resistance remains a key factor
to consider both now and in the near future. Napping, despite its
apparent ‘makeover’, is still treated with scorn or derision within
many workplaces. Putting sleep quite literally ‘to work’ in this
fashion, moreover, is not without its ironies or contradictions.
Considerable ambivalence or scepticism likewise, as we have seen,
also surrounds the use of wakefulness amongst the healthy, given
health and safety concerns, thereby calling into question some of the
assumptions and pronouncements commonly found within neuro-
ethical discourses and media debates on the supposed appeal or
temptations of ‘enhancement’ (Greely et al., 2008).
To the extent, nonetheless, that either or both strategies become
more widely accepted, if not culturally expected, practices within
certain cultural contexts, sectors, or segments of society, then the
critical issue turns perhaps as much on the eventual or potential
‘normalisation’ of workplace napping and wakefulness promoting
drugs in the 24/7 society: a normalisation which, ironically, may also
amount to a further ‘problematisation’ of sleep in the 24/7 society,
particularly if future forms of ‘optimisation’ result in greater
‘optionalisation’ if not eventual ‘obsolescence’. The latter, admittedly,
is an unlikely future scenario, given not simply the vital biological but
the vital social role that sleep plays in society as ‘remission’ or
‘release’ (cf. Parsons, 1951; Schwartz, 1970; Williams, 2005).
As for matters of historical record these prospective trends and
transformations, we have argued, in part build on long standing
pursuits and practices, both medical and non-medical, concerned
with the management if not the modification or customisation of
sleep. In part, however, we have suggested they represent signifi-
cant developments, not least in terms of the transformation of sleep
itself into a source of optimisation if not optionalisation, which in
turn resonates with prized neoliberal values such as enterprise and
efficiency in the 24/7 society.
A further point concerns the growing politicisation of sleep in
the 24-h society: biopolitical matters, that is to say, to do with the
governance of sleep and wakefulness in all its complexity and
contradictions. This moreover, in a reflexive vein, includes the role
of the social sciences themselves in these very debates: part and
parcel that is to say of the very problematisation and politicisation
of sleep we seek to study.
What future research agenda does this signal? Clearly sociolo-
gists and others in the social sciences and humanities are at an early
stage in researching these issues, as this paper attests. Much remains
to be done both conceptually and empirically in this rich new area of
research. Four key issues nonetheless, in addition to the wider socio-
historical and cross-cultural significance of these trends and trans-
formations both locally and globally, are clearly signalled here as
worthy of further and fuller sociological exploration:
(i) The impact and influence of developments in sleep science
and sleep medicine on how we understand and relate to our
biological bodies; and the ways in which this translates into
how we negotiate, manage and problematise sleep and
wakefulness in contemporary society;
(ii) The ways in which the adoption or rejection of new technol-
ogies such as modafinil and/or behavioural strategies like
daytime napping act to create and constrain new choices and
possibilities for action on the self in the name of health/
improvement/enhancement; and the ways in which these
strategies combine or are sequentially phased in different
circumstances, contexts and across the life course;
(iii) The potential for the ‘normalisation’ and ‘stratification’ of
customisation strategies within different settings and sections
of the 24/7 society, including further detailed case-studies and
comparative research in particular work cultures, starting
perhaps with medicine or other safety-sensitive occupations
vis-à-vis other cognitive/information-rich or corporate sectors
of the economy;
(iv) The broader questions this raises regarding not simply the
biomedicalisation but the biopolitics of sleep and wakeful-
ness; questions to do with the governance of alert/sleepy
bodies, the commercialisation of life and the future of
humanity.
Our paper, then, is perhaps best read as a preliminary explora-
tion of these issues on the one hand, and a programmatic call for
more research along these lines on the other hand: part and parcel
indeed of the increasing and long overdue attention to sleep
matters within the social sciences and humanities today. As for the
question posed in the title of the paper, the answer is that the actual
and prospective customisation of sleep in the 24/7 society does
indeed take us beyond medicalisation to broader processes of
biomedicalisation and politicisation: biopolitical matters of gover-
nance and ‘optimisation’ in neoliberal times which themselves are
complex and contested.
Acknowledgements
The authors should like to thank Stefan Timmermans and two
anonymous reviewers for their helpful comments on an earlier
draft of this paper.
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