An indefinite object

So much for ontological politics. One of Mol’s points – that the social and the (non-social) real are all mixed up in practice – is well illustrated here, as is her insistence on the importance of a praxiography which explores how realities are constituted in practice rather than taken to be fixed. But now I want to return to the strategy of Mol’s that I put aside above: the possibility of creating different objects. Mol’s own example was about the measurement of success of two different interventions. In the study that she cited it turned out that the surgical procedure of PTA (inflating the balloon in the diseased vessel) improved the ankle–arm index, that is the measured pressure of blood to the diseased limb. On the other hand, it made no difference to the onset of inter- mittent claudication: after PTA patients could walk no further without the onset of pain than before. However, the results for walking therapy were the other way round. Patients given such therapy were able to walk further, but there was no discernible improvement in the measurements of their ankle–arm index. So how to deal with this discrepancy? One can imagine various possi- bilities, but in the case she describes the response was to create two different atheroscleroses: walking distance, and ankle–arm index.

We have just come across a similar manoeuvre in the case of alcoholic liver disease. This was the argument put by Dr Nixon, the community health consultant. Most professionals in the hospital believed that improvement demanded total abstinence. But when we put this to him, Dr Nixon didn’t agree:

No. It is not just a question of being substance-free. It also has to do with improving other aspects of life. Such that the substance, or the alcohol, becomes secondary. Then people begin to be free, free of the substance, and enjoy health and a social life. These become more important than the substance. So, for instance, success would be talking with the children a couple of times a week in the evening, instead of going to the pub the whole time.

Dr Nixon is much less interested in abstinence (the equivalent of a perfect ankle–arm index) than he is in enjoying health and a social life (equivalent to the disappearance of intermittent claudication). In effect, then, he has created a different object. In his practice, alcoholic liver disease has been turned into something different.

Empirically there is nothing very surprising about this. Remember that the consultants and the nursing staff in the hospital are confronted with patients whose drinking has led to their hospitalisation. In many cases they are gravely ill, and sometimes they are close to death. Dr Nixon’s patients have some kind of ‘drinking problem’ or they would not be talking to him, but they are not being wheeled into Accident and Emergency, and in many cases they are holding down jobs and have partners and children.

So the fact of the multiplication of objects should not surprise us: if Dr

Warrington, Dr Nixon (and the general practitioner Dr Bowland too) are caught up in the enactment of different alcoholic liver diseases and different contexts for those diseases, then this is to be expected. But in the course of the study Singleton and I also discovered something more disconcerting. This was that our own object of study and its contexts were continually moving about. Thus we not only found that we were shifting between different alcoholic liver diseases but also, and uneasily, between different problems. Initially we were invited to explore the diagnosis and treatment of alcoholic liver disease. Call this object number one. But as we moved into the study and interviewed the professionals we found that we were often talking about liver disease (object number two) rather than alcoholic liver disease. Or, more specifically, we were discussing alcoholic cirrhosis (number three). Or, very commonly, the talk was of alcohol abuse and its implications for individuals and the health care system (four). Or (not necessarily the same thing) it was of alcoholism (five). Or (as we have just seen for the case of Dr Nixon) it might be about overall quality of life in relation to substance abuse (six). The issue, then, was how to think about this displacement: the fact that the object of study seemed to slip and slide from one interview to the next.

There were moments when we castigated ourselves. We had been invited to consider the system for diagnosing and treating alcoholic liver disease and here we were, shifting between different topics and objects. Indeed, we had promised (in the face of some scepticism, it must be said, on the part of the professionals) to map out that system:

In the first stage of the research we will seek to map out the processes involved in diagnosing and treating a ‘typical’ patient with alcoholic liver disease – so to speak, the typical trajectory of a patient within the organisation of medical care.69

This being the case, it seemed uncertain whether we should be allowing ourselves to discuss (say) alcoholism or quality of life. Instead we sometimes felt that we should be taking a firmer grip on ourselves and our study, and working to focus it better, to keep it on message. As time went on, however, we came increasingly to the view that this was not only impossible, but might also be counterproductive. We found, for instance, that the different ‘maps’ for patient trajectories that we derived from our informants in different sites didn’t really coincide with one another:

sometimes patients are referred from the hospital to Castle Street [the Alcohol Advice Centre]. Then they may be given wrong expectations about what can be achieved, and they get lost to the system. In the hospital it depends on who they see. The psychiatric liaison nurses... are very experienced, but junior consultants do not have that experience. Wrong expectations are built up, when patients think they can come straight to Castle Street, and do not realise that it is by appointment only.70

The hospital map didn’t coincide with the Castle Street map. This kind of complaint recurred and recurred:

Links with GPs are a bit variable. Some don’t refer to Castle Street at all. Counsellors will only see people who refer themselves.

Perhaps this was because the health care system was disorganised, but the consequence was that ‘mapping’ as a metaphor didn’t work too well. And trying to trace this in terms of our supposedly major interest, alcoholic liver disease, didn’t work either. The reason was that alcoholic liver disease was very often difficult to separate from the other related objects. There might, indeed, be moments when it was possible to separate it from other topics into which we were slipping. Perhaps, for instance, this was possible in the pages of the textbook, or in discussion with a consultant such as Dr Warrington. But predominantly, and in most of the sites, the condition was linked more or less strongly and with greater or lesser specificity, with alternative, partially connected, foci of the kind I have listed above. The consequence was that it became natural to attend to one of the other foci, or some mix of objects, rather than insisting rigidly that talk should focus on alcoholic liver disease itself. For instance, as we have seen, Dr Nixon wanted people to be ‘free of the substance’. It wasn’t that he was in ignorance of alcoholic liver disease medically understood. It wasn’t that he denied its relationship to substance addiction. But the real focus for him was quality of life and this particular version of personal freedom – not enzymatic, histological and anatomical changes in the liver.

We were involved – and participating – in slippage. But how to think about this? As I have just noted, we gradually came to think that this was not simply a sign of shoddy method, a failure to get a grip on something definite. Instead, we slowly came to believe that we were dealing with an object that wasn’t fixed, an object that moved and slipped between different practices in different sites. This was an object that, as it moved and slipped, also changed its shape. It was a shape-changing object that, even more misleadingly, also changed its name. It was an object whose slippery shape-changing also reflected what the managers and other participants took, perhaps correctly, to be an expression of organisational dislocation, fragmentation and disorganisation. So its relevant context out there changed too.

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