Differences in perspective

To write in this common, indeed habitual, way is a form of perspectivalism. It buys into, enacts, and presupposes a classic Euro-American version of out- thereness. An atherosclerotic reality out there is made anterior to, and independent of medical intervention. It is both definite in form and singular. With this framing of out-thereness the first task is to work out what reality is: for instance, the condition of Mrs Tilstra’s leg vessels, and the location of stenoses in those vessels. Then, the second task is to intervene in a way that will help her. Surgeons and their medical colleagues are committed to a strong version of out-thereness: like perspectival artists, or the Salk Laboratory scientists, they assume that they are all addressing the same reality. And, to be sure, sometimes everything works out smoothly. Pain on walking, clinical examination, angio- graphy, duplex, surgical intervention, and pathology – all may fit together to produce a single co-ordinated atherosclerosis.

Sometimes. But sometimes relevant practitioners instead find that they are faced with poorly co-ordinated realities. So what do they do then? Here is one example:

The pathologist: ‘You, since you’re so interested in atherosclerosis, you should have been here last week. We had this patient, a woman in her seventies. She had renal problems. Severe ones too. So she was admitted. And the next day she died. Paff, from one moment to the next. The nephrologists were aghast, and so, of course, was her family. So we were asked to do an obduction. Her entire vascular system was atherosclerotic. One of her renal arteries was closed off, the other almost. It was a wonder her kidneys still did anything at all. It was hard to see where they got their blood from. And it was more or less the same for every other artery we took out: they were all calcified. Carotids, coronary arteries, iliac arteries: everything. Thick intimas, small lumens. And she’d never complained. Nothing. No chest pain, no claudication, nothing.’

(2002, 45–46)

Here is a second example:

‘Here, look at this. Have you seen the pressure measurements of Mr Iljaz? It’s unbelievable. I can’t believe it. If you look at these numbers he can hardly have any blood in his feet at all. And he came to the outpatient clinic all alone, on his motorbike. Said he had some pain. I can’t believe it. Some pain. On these figures alone I’d say here’s someone who can’t walk at all. Who’s screaming.’

(2002, 64)

And here is a third:

[Mrs Takens’s bypass] might be occluded, for the angiographic picture shows no dye beyond a critical point: the white stops abruptly. The duplex, however, still shows a peaking graph below this point. Flow. One of the radiology residents asks: ‘In a case like this, when the angio says “closed” and the duplex says “open”: what should one believe?’ Two surgeons, speaking with a single voice, say: ‘Duplex’.

(2002, 83)

These are examples of contradictions: between the results of the pathology laboratory and the life of the patient (first case); between the life of the patient and measurements from the clinic (second case); and between angiography and duplex (third case). But what is their significance?

First, contradictions are important in the day-to-day practice of medicine. For though medical professionals usually work with a strong, perspectival version of out-thereness, this is only a means to the more important end of intervening and helping the patient. Their major preoccupation is in working out what to do. In an ideal world all the indications add up and fit together: they are different but compatible in-here perspectives on a single out-there reality. But since the world is not perfect often those involved need to work out how to act in the face of conflicting indications. Their world is quite unlike that of the Salk scientists. The latter are concerned with fixing reality, with truth, but in practice if not in theory the medical professionals often have to work with multiple possible truths.45

Second, this points to the need for judgements, and for rules of thumb for making judgements. These grow out of past experience, research, conversation and reading. The craft of surgery. For instance, why did the two surgeons both say ‘duplex’ in the same breath in the quotation immediately above? Mol’s text continues so:

And then one of... [the surgeons] tells how he once studied seventeen cases like this: patients whose angiography showed an occlusion while their duplex showed flow. In all seventeen cases duplex proved to be in line with

the findings upon operation. ‘It was only seventeen cases, so I couldn’t publish it. But there were no exceptions.’

(2002, 83)

Here surgery is being used as the ‘gold standard’ to determine the nature of atherosclerosis, and duplex is being treated as the better guide to reality. But Mol also shows that in many (perhaps most) other contexts it is angiography that is used as the ‘gold standard’ to determine the accuracy of duplex (a much more recent technology) rather than the other way round. The implication is that that what counts as the best depends on circumstances (2002, 56). Rules, as Wittgenstein (1953) long ago showed, do not suggest their own proper application.

So there are more or less variable and situated rules for discriminating between contradictory versions of atherosclerotic reality, and deciding, in practice, what that reality is. For fixing it in practice. And, given the frequency of contradictions, such rules are endlessly deployed. How, for instance, could Mr Iljaz have come to the hospital outpatient clinic on his motorbike when he had so little blood in his feet? When he should have been screaming in pain? This is a puzzle:

‘Yeah, that really is something’... nods [a senior internist], ‘but we’ve seen cases like that before. Probably these people have only become worse very gradually. What happens is that their muscle metabolism alters. As long as people have time for it, the adaptation may go a very long way.’

(2002, 65)

This is one way of explaining away inconsistency, of turning it into apparent inconsistency. Another is the possibility that his diabetes may have led to degeneration of the peripheral nerves – in which case Mr Iljaz may not be able to feel pain in his legs. A third is that Mr Iljaz, who is an immigrant, may not speak Dutch well enough to explain how much pain he is actually feeling:

‘Yeah, come to think of it, he may have underreported his complaints. His Dutch was poor.’

(2002, 66)

These are perspectives on difference that tend to explain it away. But what are the implications of this? It is tempting to say that the professionals are trying to cover up inconsistencies and even their incompetences. However this suggestion, common though it is in the literature of medical sociology, is surely only part of the story. More important in the present context is that such stories help to sustain a strong perspectival and singular version of out-thereness even as they manufacture multiple realities. They assume, and at the same time help to enact, the standard version of Euro-American metaphysics while also crafting something different. The implication is that in the present incomplete,

uncertain, and untidy circumstances, we may not have full insight into either Mr Iljaz’s particular condition or atherosclerosis in general. But nevertheless his condition, and the disease, are both visible out-there. They are out-there not just vaguely, but in all the different specifics we have discussed. They are independent of the investigations of medical science, they precede diagnosis, they are definite, and they are singular. It is a technical or practical matter if we are not yet properly clear of their attributes. In this way Euro-American meta- physics preserves itself in the face of possible contra-indications.

Дата добавления: 2015-11-14