Doctors, scientists, and patients have long grappled with the dubious nature of “certainty” in medical practice. To help navigate the chaos caused by ongoing bodily change we rely on scientific reductions and deductions. We take what we know now and make best guesses about what will be. But bodies in flux always outpace the human gaze. Particularly in cancer care, processes deep within our bodies are at work long before we even know where to look. In the face of constant biological and technological change, how do medical professionals ultimately make decisions about care?
Bodies in Flux explores the inventive ways humans and nonhumans work together to manufacture medical evidence. Each chapter draws on rhetorical theory to investigate a specific scientific method for negotiating medical uncertainty in cancer care, including evidential visualization, assessment, synthesis, and computation. Case studies unveil how doctors rely on visuals when deliberating about a patient’s treatment options, how members of the FDA use inferential statistics to predict a drug’s effectiveness, how researchers synthesize hundreds of clinical trials into a single evidence-based recommendation, and how genetic testing companies compute and commoditize human health. Teston concludes by advocating for an ethic of care that pushes back against the fetishization of certainty—an ethic of care that honors human fragility and bodily flux.
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Bodies in Flux
Scientific Methods for Negotiating Medical Uncertainty
By Christa Teston
The University of Chicago PressCopyright © 2017 The University of Chicago
All rights reserved.
Not only is everything changing, but all is flux. That is to say, what is is the process of becoming itself, while all objects, events, entities, conditions, structures, etc., are forms that can be abstracted from this process.
David Bohm, Wholeness and the Implicate Order
Medicine is a heterogeneous coalition of ways of handling bodies, studying pictures, making numbers, conducting conversations. ... There is multiplicity even inside medicine's biomedical "core."
Annemarie Mol and Marc Berg, introduction to Differences in Medicine
After gradual loss of his mobility and speech, on June 17, 2014, my paternal grandfather died of multiple system atrophy — a rare and relatively mysterious degenerative disease that affects the brain. Fewer than twelve months later, at only age fifty-nine, my uncle died of an aggressive form of brain cancer. As I grieve for my grandmother, Bernice, who in one year lost both her son-in-law and her life partner of five decades, I am struck by the degree to which medical professionals struggled to name and navigate our loved ones' illnesses. Because disease seemed to sneak up on my grandfather and uncle and then slowly whittle away at their brains and bodies, I've become hyperaware of my father's tendency to repeat a story for the second or third time. When dad suffers a minor injury now and then because of what appears to be mere clumsiness or overexertion, I worry. Concerned that his forgetfulness, muscle pulls, and pain might be signs or symptoms of something ominous, I try and take comfort in recent medical tests and scans that indicate dad's brain and body are in pretty good shape.
Uncertainty posed by the ambiguous space between living and dying is mitigated, albeit only in part, through medical evidence. But how are evidential worlds assembled from bodies in perpetual flux? From where does medicine's evidential weight hail? What protocols and procedures elevate everyday biological activities to positions of argumentative authority? This book seeks answers to such questions through an exploration of the backstage, behind-the-scenes biomedical practices that materially render medical evidence both visible and actionable. Bodies in Flux is inspired by medical professionals' success with and failures at navigating not knowing. Each chapter investigates one of four specific scientific methods for negotiating medical uncertainty in cancer care: evidential visualization, evidential assessment, evidential synthesis, and evidential computation.
Defining and diagnosing disease is a kind of quixotic empiricism. It requires taking what's known now and making best guesses about what's to come. Yet, as physicist and philosopher David Bohm (1981) argues, "all is flux" (61). Inspired by partnerships with nature, premodern medical and scientific practitioners once used astrological evidence to manage bodily flux. For example, constellations once aided in predicting astral circumstances of birth, controlling parts of a body, and determining when and where to let blood or take medicine (French 2003, 132). Today's attempts at managing bodily flux involve monitoring corporeal symptoms and modeling risks. From telescopes to stethoscopes to microscopes, biomedical projections have always resulted from human and nonhuman partnerships. The always already collaborative nature of attempts at forecasting corporeal futures complicates contemporary biomedical practice and precision. Bodies in Flux explores such complications.
I invoke "flux" not only in reference to cancer care's corporeal contingencies but also to orient readers' attention toward scientific indeterminacy (Barad 2007) — the kind of contingencies and indeterminacy that Heraclitus may have had in mind when he famously declared the impossibility of stepping into the same river twice. As a concept, flux highlights the evidential complexity of being (a body) in the world. In rhetorical theory, flux counters the notion that rhetoric, and decision making in particular, consists of discrete and autonomous elements such as audience, purpose, or context. Contesting the reductive nature of a or the rhetorical situation, Jenny Edbauer (2005), Louise Weatherbee Phelps (1991), Laurie Gries (2015), and several other rhetoric scholars have advocated for an ecological view of rhetoric that situates suasive activity within (and because of) a "wider sphere of active, historical, and lived processes" (Edbauer 2005, 8). An ecological model of rhetoric characterizes "rhetoric" as a verb. A performance. A constant process of unpredictable unfolding. To study rhetoric, therefore, is to study flux and flow. To study rhetoric is to explore processes of becoming (Bohm 1981).
In the following chapters, I trace processes of becoming in the biomedical backstage. That is, I trace how modern medicine does rhetorical work. To do this, I identify and analyze biomedical practitioners' material-discursive negotiations with matter, movement, and time. I do so motivated by the troubling awareness that well prior to medical practitioners' attempts at understanding my grandfather's, uncle's, and father's corporeal conditions through freeze-framed abstractions (such as medical images or blood tests), processes deep within their bodies were and are always at work. Material actions — some seen, some unseen — perform our bodily being long before doctors even know to look.
Bodies in Flux is about and for those who compose, communicate, contend, and cope with biomedical evidence as material made to mean. Each chapter's investigation of medical practitioners' attempts at managing bodies' inherent indeterminacy is written with patients, practitioners, policy makers, technical communicators, rhetoricians, medical humanists, and science and technology scholars in mind. Exigencies for a book about how biomedical evidence is made to mean are abundant. In response to evidence-based medicine's fetishization of medical evidence many wonder: Whose evidence? What counts as evidence? And how is evidence tallied and made to matter? Commoditized, direct-to-consumer genetic testing kits and government-mandated electronic medical records invite additional scrutiny: Who owns my medical evidence? Who should or should not have access to it? Evidential complexities such as these have implications not just for decision making. Evidential complexities such as these also have economic and ethical effects.
The rate of women in the United States choosing to undergo what is now referred to as a "bilateral risk-reducing mastectomy" has increased by 50 percent in just the last five years. As I write this, these rates, along with what is colloquially referred to as the "Angelina Jolie effect," have sparked a cultural firestorm of debate about medical certainty, women's choice, and biomedical ethics. In an effort to demystify (if not normalize) the procedural and surgical implications of her decision to undergo a preventative double mastectomy, Jolie (2013) detailed three months of medical procedures and experiences in a New York Times op-ed. Since the op-ed's publication, debate has ensued about whether testing positively for BRCA1, a genetic marker that when present increases a woman's risk of developing breast and ovarian cancer, ought to be grounds enough for a doctor to recommend preventative or "risk-reducing" surgery on otherwise healthy bodies. Jolie's mother died of cancer at only fifty-six years of age. Presumably, Jolie was well versed in statistical probabilities associated with the likelihood that she, too, would suffer a similar fate. For many women in Jolie's predicament, personal experience and statistical probabilities are the only evidences they have to go on. I invoke the Angelina Jolie effect here not as an endorsement of her choice but to draw readers' attention to the complexity of weighing evidence against perceptions of risk when making medical decisions.
Regardless of how readers view Jolie's (no doubt privileged) choice to undergo preventative surgeries, her assertion about how cancer evokes a "deep sense of powerlessness" likely resonates among readers from every socioeconomic status. The powerlessness caused by cancer is pervasive. Genetic biomarkers, statistical analyses of survival, and characterizations such as "best practice" or "standard of care" are used routinely in cancer care, but are, by and large, mysteries to those who are unfamiliar with such specialized practices and discourses. We can assume that, in conversations with her doctor, Jolie was provided with accurate and useful information about her diagnosis, prognosis, and options for treatment. Bodies in Flux augments and perhaps supplements such private, doctor-patient conversations and attends to the methodological materiality associated with doing evidence-based cancer care. Mindful of the millions of people who live in a persistent state of prognosis (Jain 2013), I highlight how, in evidence-based medicine, methods materialize matter in meaningful ways.
After nearly a decade of studying evidential construction in the biomedical backstage, I have identified four specific methods with which medical professionals attune to corporeal flux in cancer care: evidential visualization, assessment, synthesis, and computation. To illustrate, consider the backstage, material-discursive labor that had to take place prior to my uncle's official cancer diagnosis. First, his disease was visualized. To do this, doctors worked with a host of technologies to capture, quantify, and interpret my uncle's body data (e.g., tumor size and placement, additional health concerns, comorbidities). Second, medical professionals assessed these body data. They relied on statistical calculations of survival by comparing previous patients' experiences to my uncle's unique disease experiences. Third, doctors reasoned about possible prognoses and treatment options by invoking standardized guidelines — guidelines that were produced from syntheses of previous patients' body data. And to better understand the genetic complexities of life-threatening diseases like my uncle's, medical professionals perform computational analyses of similar patients' DNA. By the time any of these evidences are "accommodated" to patients and their care networks (Fahnestock 1986), details surrounding the material-discursive design work I just described are black-boxed (Latour 1987). For Latour, "black box" is a construct "used by cyberneticians whenever a piece of machinery or a set of commands is too complex" (2–3). Black boxes collapse complexity into mere input and output. Black boxes coalesce disorder into something that "resembles an organised whole. ... When many elements are made to act as one, this is what I will now call a black box" (Latour 1987, 131). Bodies in Flux props open such cancer-care black boxes. It unearths scientific methods that are used to make evidence matter and mean in the biomedical backstage.
Over the last three decades, the phrase "evidence-based medicine" has become a discursive marker for rigor and reliability in biomedical practice. Specifically, evidence-based medicine is defined as "the conscientious, explicit, and judicious use of current best evidence to guide decisions about patient care" (Sackett et al. 1996, 71). Before the practice was referred to as evidence-based medicine, randomized and well-controlled clinical trials were called critical appraisals. When Gordon Guyatt made programmatic changes to McMaster University's medical school in the 1990s, he advocated for educational instruction and practices that placed proven evidence (as could be supported through critical appraisals) ahead of experts' authoritative experiences and opinions. Critical appraisals acted as guidebooks by granting practitioners a sense of randomized trials' methodological rigor. Guyatt's revisions meant that methodological rigor now trumped clinical expertise. Evidence-based medicine soon displaced expert-based medicine, and young physicians who embraced randomized controlled trials' methodological superiority and evidential authority soon found themselves empowered.
While some regard evidence-based medicine as a recent phenomenon concomitant with so-called scientific progress, for reasons I will soon describe in greater detail, I argue that medical practice has always been evidence based. Evidence-based medicine is not just an insistence on using evidence to make decisions. Medical practitioners have for centuries used evidence to make decisions. Rather, implicit in the era of evidence-based medicine is an agreement among contemporary medical practitioners that methods matter. That is, evidential worthiness and weight in modern-day biomedical practice hinges on methodological transparency and quality.
To demonstrate that contemporary evidence-based medical decision making is just as complicated as it ever was, scholars from various disciplines have sought to account for the role of affect, logic, intuition, persuasion, and experiential knowledge in medical practice (see, e.g., Denney 1999; Derkatch 2008; Graham 2011; Grossman and Leach 2008; Lambert 2006; Little et al. 2002; Mykhalovskiy and Weir 2004). Some scholars (in particular, those who characterize their work as medical rhetoric) have conducted important research about how evidence and expertise are leveraged during decision making (e.g., Charon and Wyer 2008; Derkatch 2008; Graham and Herndl 2013; Hikins and Cherwitz 2011; Majdik and Keith 2011; Schryer et al. 2009). But what do we know about the rhetorical design of medical evidences, themselves? What are medical evidences' material-discursive lineages? Until now, methods by which evidence is visualized, assessed, synthesized, and computed prior to the deliberative decision-making moment have garnered little attention from medical rhetoricians and technical communicators. While scholars in medical rhetoric (myself included) have conscientiously pored over transcripts from impassioned doctor-patient interactions and pharmaceutical policy deliberations, we have remained largely unfamiliar with (if not ignorant of) the evincing methods with and on which those conversations and deliberations are predicated.
As we seek answers to questions about whose evidence counts and what counts as evidence, methods for making biomedical evidence meaningful invite if not require constant critical attention. Examining methods with which medical professionals design evidence draws attention to and demystifies but also makes strange modern medicine's prophetic practices. As objects of study, scientific methods for navigating medical uncertainty are complex processes of becoming (Bohm 1981). Human, nonhuman, and computational actors collaboratively design the evidence with which decisions are later made. Understanding how evidential materials do rhetorical work in the biomedical backstage — specifically, how visuals evince, and how evidences are then assessed, synthesized, and computed — makes for more informed and agential patients, technical communicators, and participants during individual and public policy decision making. I argue that the material-discursive labor required to elevate quotidian biological processes to evidential status is not merely epiphenomenal to acts of diagnosis, treatment, and prognosis.
So, how does backstage, invisible design work render the argumentative grounds on which a medical decision may be made? To answer this question, each chapter props open the following biomedical, backstage black boxes: pathologists' and radiologists' methods for imaging cancer; policy makers' statistical methods for assessing survival probabilities; oncologists' methods for synthesizing evidence so that cancer-screening protocols can be established; and direct-to-consumer genetic testing companies' computational methods for commoditizing health futures. Examinations of scientific methods for negotiating medical uncertainty build on what Latour (1987) calls contexts of discovery, or science in the making. In each case study, I explore how human, nonhuman, and computational collaborations shape evidences that inform medical decisions — decisions that help to allay the deep sense of powerlessness often bred by the threat of disease and diagnostic uncertainty. Understanding this labor is important if medical professionals truly value shared or patient-centered decision making (cf. Charles et al. 1997, 1999). And since multiple publics are increasingly incorporated into democratic decision making about medical and scientific policies, a rich understanding of how evidences are rhetorical constructions might help lessen the degree to which the specter of error-free, scientific objectivity presides over such deliberative events. Finally, disclosing the rhetorical underpinnings of how medical professionals create diagnostic and prognostic order from biomedical chaos might help to advance nuanced definitions for and practices of care (cf. Mol, Moser, and Pols 2010).
Excerpted from Bodies in Flux by Christa Teston. Copyright © 2017 The University of Chicago. Excerpted by permission of The University of Chicago Press.
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Table of ContentsAcknowledgments 1. Evidential Matter(s)
2. Evidencing Visuals
3. Assessing Evidence
4. Synthesizing Evidence
5. Computing Evidence
6. Dwelling with Disease Appendix A. ODAC Hearings Post-Avastin, 2011–2013 (Not Including Pediatric Hearings)
Appendix B. CSR Outlines
Appendix C. Genetic Testing Methods and Techniques, 1950–1990