The Body Multiple-CL
By Annemarie Mol
Duke University Press Copyright © 2003 Annemarie Mol
All right reserved. ISBN: 9780822329022
Chapter One doing disease
A Movement between Fields
This is a study in empirical philosophy. Let's begin with the empirical. The stories I will tell you in this book are mostly situated in a university hospital in a medium-sized town in the center of the Netherlands, Hospital Z. For four years I went there once or twice weekly. I had an identity card that allowed me to leave my bicycle behind a fence and drink free coffee from the omnipresent vending machines. I had a library card and the use of a desk in a succession of crowded rooms. I had a white coat. And I observed.
I would go to the professor who headed a department and explain my purpose: to investigate the way the tensions between sources of knowledge and styles of knowing are handled inside present-day allopathic medicine-or at least one of its exemplars. I would explain what made "atherosclerosis in the lower limbs" a suitable case for my purpose and what I hoped to learn in their department. I presented myself as both insider and outsider, having received basic training in medical school as well as extensive training in philosophy. And I gave the name of the professor of internal medicine supporting mystudy. Each of the professors thus approached reacted in a friendly way. They all emphasized that academic hospitals must encourage research. My particular research plans made some interested and some skeptical. Others simply were indifferent. But after some further questions I would invariably be sent to someone one or more steps down the hierarchy to talk about and practically arrange my observation.
So I sat for many mornings behind vascular surgeons and internists doing their outpatient clinics, observing some three hundred consultations. (All surgeons and internists I observed for this study were men, and I will not hide that fact, so I use the generic "he" whenever I write about "the doctor," even though one of the pathologists whom I observed was a woman. Yes, this is a fading historical moment. The profession is undergoing a rapid gender change. But that is another story. One more complication left out here.) In university hospitals, both physicians and patients are used to observers: there are always students and junior doctors around who need to learn something. Yet I was surprised by the calm with which my presence was accepted-for I found these observations rather intimate. Patients tell about so much and undress so often. Although that is difficult for some and a relief to others, my presence behind the attending doctor hardly seemed to make a difference. When it risked to do so, I skipped a visit (once when a patient asked for it, several times when a doctor did, and once when I recognized someone I knew vaguely and left of my own initiative). The other transgression was into the privacy of the doctors. I was in a position to observe all kinds of details about the way they work. Some of them were visibly uneasy about the fact that I might judge the degree to which they were humane and kind in their interactions with patients. But (though that was sometimes difficult to resist) I wasn't out to make such judgments. Nor did I want to judge the so-called technicalities of their diagnosis and treatment. I wanted my observations to be a means to get to know their standards, rather than an occasion to apply my own.
This made me shift sites and move around in the hospital. I observed technicians handling diagnostic tools in the vascular laboratory. I followed the tracks of radiologists and pathologists in their dealings with leg arteries. I went for months to the weekly meetings where the treatment options for patients with complicated cases of vascular disease were discussed. I witnessed several operations. Spent some days in the research laboratory of the hematologists. Held interviews or had conversations with epidemiologists, physiologists, internists, surgeons, and general practitioners. A couple of them read my articles and we talked about their reactions. I also went to the library and studied the textbooks and journal articles written, or mobilized as a resource, by "my doctors" and, when the references and my curiosity took me there, compared them with other publications. For two years I followed the monthly research colloquium on atherosclerosis. I coauthored with a junior doctor an article about the introduction of a diagnostic protocol. I supervised a medical student who interviewed vascular surgeons in several smaller hospitals and another one who analyzed discussions about the intake of cholesterol. And, finally, I had the temporary luxury of a research assistant-Jeannette Pols, a philosopher like myself, moreover trained as a psychologist-who held long patient interviews, transcribed them, talked them over with me, and coauthored publications about this material. She also was a good sparring partner with whom to discuss my work.
Discussion was also what I sought in other worlds, outside the hospital. I could seldom go to those places by bicycle, for they were a lot farther away-and yet they were less alien to my writing and talking self. They were departments of philosophy, anthropology, sociology, or science and technology studies. I attended conferences and listened bored or fascinated to speakers presenting papers to five or fifty listeners. I read journal articles, wrote them, reviewed them. I went for talk-walks on lakesides or chatted over dinners. I was cross-examined about my field, my method, my purpose, my theoretical ancestors. Often such exchanges took place in an odd version of the English language, a transportation device that poses some difficulties to those who have not grown up with it, but reaches far. So though my stories come from the hospital in the town where I live, they went with me to many other places. To my intellectual friends and enemies in places like Maastricht, Bielefeld, Lancaster, Paris, Montreal, San Francisco. They managed to travel, my stories about leg vessels and pain. Immersed in theoretical arguments about the multiplication of reality.
For even if there are a lot of empirical materials in this book, this is not a field report: it is an exercise in empirical philosophy. Let's shift to the philosophy. The plot of my stories about vessels and fluids, pain and technicians, patients and doctors, techniques and technologies in hospital Z is part of a philosophical narrative. In conformity with the dominant habit of that genre, I'll give away the plot right here, at the beginning. It is this. It is possible to refrain from understanding objects as the central points of focus of different people's perspectives. It is possible to understand them instead as things manipulated in practices. If we do this-if instead of bracketing the practices in which objects are handled we foreground them-this has far-reaching effects. Reality multiplies.
If practices are foregrounded there is no longer a single passive object in the middle, waiting to be seen from the point of view of seemingly endless series of perspectives. Instead, objects come into being-and disappear-with the practices in which they are manipulated. And since the object of manipulation tends to differ from one practice to another, reality multiplies. The body, the patient, the disease, the doctor, the technician, the technology: all of these are more than one. More than singular. This begs the question of how they are related. For even if objects differ from one practice to another, there are relations between these practices. Thus, far from necessarily falling into fragments, multiple objects tend to hang together somehow. Attending to the multiplicity of reality opens up the possibility of studying this remarkable achievement.
Philosophy used to approach knowledge in an epistemological way. It was interested in the preconditions for acquiring true knowledge. However, in the philosophical mode I engage in here, knowledge is not understood as a matter of reference, but as one of manipulation. The driving question no longer is "how to find the truth?" but "how are objects handled in practice?" With this shift, the philosophy of knowledge acquires an ethnographic interest in knowledge practices. A new series of questions emerges. The objects handled in practice are not the same from one site to another: so how does the coordination between such objects proceed? And how do different objects that go under a single name avoid clashes and explosive confrontations? And might it be that even if there are tensions between them, various versions of an object sometimes depend on one another? Such are the questions that will be addressed in this book. I cautiously try to sketch a way into the complex relations between objects that are done.
This book tells that no object, no body, no disease, is singular. If it is not removed from the practices that sustain it, reality is multiple. This may be read as a description that beautifully fits the facts. But attending to the multiplicity of reality is also an act. It is something that may be done-or left undone. It is an intervention. It intervenes in the various available styles for describing practices. Epistemological normativity is prescriptive: it tells how to know properly. The normativity of ethnographic descriptions is of a different kind. It suggests what must be taken into account when it comes to appreciating practices. If reality doesn't precede practices but is a part of them, it cannot itself be the standard by which practices are assessed. But "mere pragmatism" is no longer a good enough legitimization either, because each event, however pragmatically inspired, turns some "body" (some disease, some patient) into a lived reality-and thereby evacuates the reality of another.
This is the plot of my philosophical tale: that ontology is not given in the order of things, but that, instead, ontologies are brought into being, sustained, or allowed to wither away in common, day-to-day, sociomaterial practices. Medical practices among them. Investigating and questioning ontologies are therefore not old-fashioned philosophical pastimes, to be relegated to those who write nineteenth-century history. Ontologies are, instead, highly topical matters. They inform and are informed by our bodies, the organization of our health care systems, the rhythms and pains of our diseases, and the shape of our technologies. All of these, all at once, all intertwined, all in tension. If reality is multiple, it is also political. The question this study provokes is how the body multiple and its diseases might be done well. This question will not be answered here. Instead, I'll map out the space in which it may be posed.
The Perspectives of People
This is a philosophical book of a specific, that is, empirical, kind. It draws on social scientific and, more notably, ethnographic methods of investigation. But it does not just import these, it also mingles with them. For if I use ethnographic methods here, it is to study disease. That physicalities may be studied ethnographically is a quite recent invention. For a long time, "disease" was the unmarked category of anthropology and sociology of medicine. As the state of a physical body it was an object of biomedicine. Doctors told the truth about disease, or at least they were the only ones able to correct each other in so far as they didn't. Social scientists were careful not to get mixed up in this body-talk. Instead, they had something to tell in addition to existing medical knowledge. They pointed out that the reality of living with a disease isn't exhausted by listing physicalities. There is more to it. Apart from being a physical reality, having a disease has a meaning for the patient in question. A meaning that is open to investigation. Listen to the story about Mr. Trevers (an invented name; all names used in field stories are invented):
Mr. Trevers sits in a chair in the surgical ward. Sure, he's quite willing to answer a few questions. Jeannette, the interviewer, sits down next to him. She casually asks if putting on the tape recorder is a problem. No, it isn't. They talk about the wound on Mr. Trevers's foot. It was the reason for the operation on his leg arteries a few days before. "My problem was not that it hurt," Mr. Trevers says, "but that this wound didn't go away. It was quite frightening. This gaping hole. I didn't go to the doctor at first, when that beam fell on my foot. I didn't care about the pain. But when it never went away, my wound, but only became bigger, then I got scared. And I went to see my general practitioner. She sent me in to the hospital. And now I've got two diseases. I've got atherosclerosis, they tell me, and diabetes. I've also got diabetes."
Mr. Trevers became frightened when his wound didn't heal. To the vascular surgeon who has operated on him, this fear is hardly relevant. It is relevant that Mr. Trevers finally decided to go and see a doctor. But once he did, well, fear, this is "one of the things people feel," as is an aversion of wounds that stay "gaping holes." If there is time, Mr. Trevers may be allowed to talk about his feelings. But they need not be written down in his surgical files. As "a good doctor" the surgeon may explain some facts in an attempt to reassure his patient. But "fear" is not a part of Mr. Trevers's vascular disease, nor of his diabetes.
As a complement to this, social scientists have made it their trade to listen for feelings when they interview patients. And they have persistently and severely criticized doctors for neglecting psychosocial matters, for being ever so concerned about keeping wounds clean while they hardly ever ask their patients what being wounded means to them. In addition to attending to blood sugar levels, bad arteries, wounds, and other physicalities, or so social scientists have been arguing in all kinds of ways, physicians should attend to what patients experience. This is how they have come to phrase it: in addition to disease, the object of biomedicine, something else is of importance too, a patient's illness. Illness here stands for a patient's interpretation of his or her disease, the feelings that accompany it, the life events it turns into.
In the social sciences, "disease" and "illness" were separated out as two interlinked but separate phenomena. Social scientists put "illness" on the research agenda. Shelves of books and volumes of journals were dedicated to it. Interviews were amassed, the attribution of meaning was analyzed, and ways of therapeutically attending to it were designed. All along social scientists left the study of disease "itself" to their colleagues, the physicians, until they started to worry about the power a strong alliance with physical reality grants to doctors. Then, social scientists gradually began to stress that reality isn't responsible all by itself for what doctors say about it. "Disease" may be inside the body, but what is said about it isn't. Bodies only speak if and when they are made heavy with meaning. In Mr. Trevers's case, a wound that doesn't heal is said to be a sign that points toward diabetes and atherosclerosis of the leg arteries. But this isn't necessarily so: this is a meaning that has been attributed. Such attributions have a history, and they are culturally specific. This opens them up for historical and social scientific investigations.
In this semantic approach, social scientists no longer primarily take doctors to be colleagues, colleagues who may be criticized for not listening to their patients carefully enough, but into whose object domain-physical reality-the social scientist wouldn't dare to venture. Instead of colleagues, doctors become the social scientists' objects. What doctors say when they talk about diseases is investigated with the theoretical tools that were crafted for studying the words of patients. Like patients, or so it is said, doctors have a perspective. They attribute meaning to what happens to bodies and lives. Even though doctors interpret the bodies and lives of others, whereas patients talk primarily about their own.
Perspectivalism turns doctors and patients into equals, for both interpret the world they live in. But to say this is also to reinforce their division, because the interpretations doctors and patients give must differ, linked as they are to the specific history, interests, roles, and horizons of each group. In perspectivalism, the words "disease" and "illness" are no longer used to contrast physical facts with personal meaning. Instead, they differentiate between the perspectives of doctors on the one hand and those of patients on the other.
Excerpted from The Body Multiple-CL by Annemarie Mol Copyright © 2003 by Annemarie Mol. Excerpted by permission.
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