Medical metaphysics

The body multiple: ontology in medical practice Annemarie Mol Durham (NC): Duke University Press; 2003 196 pp US$59.95 (cloth) ISBN 0-8223-2902-6 US$19.95 (paper) ISBN 0-8223-2917-4

ontology: the branch of metaphysics dealing with the nature of being — Canadian Oxford Dictionary

What is an atherosclerosis? A narrowed lumen. A thickened intima. A crunching sound under the pathologist's knife. Pain on walking. Arterial pressure drop in the lower leg. A genetic liability. An outcome of poor diet. In the “empirical philosophy” of Annemarie Mol, atherosclerosis, or any disease, is never singular, but multiple. It is a “composite reality.”

For physicians this is hardly problematic. Differences in “perspective” are natural and necessary, provided they do lead to a breakdown in practice. (Not that “perspective” is a concept that Mol accepts, for it presumes that there is one, single entity “out there” that is being observed.) She writes, “Atherosclerosis is a word [different specialists] use when they want to talk to one another.” Pathologists deal with “their” atherosclerosis, the one under the microscope; vascular surgeons deal with another version, the one under the knife. Radiologists deal with different atheroscleroses, whose addresses are inferred through angiography or duplex ultrasonography. The family physician responds to the version reported by the patient and corroborated through physical examination: pain, reduced mobility, frustration, apprehension. Everyone involved has his or her own understanding to act on, and it matters little whether there is one, single thing that atherosclerosis really is. As Mol writes, “a plaque cut out of an atherosclerotic artery is not the same entity as the problem a patient with atherosclerosis talks about in the consulting room”(p. vii). For the driving questions in medicine are practical: what to do. To treat, or not to treat. If to treat, then how.

Hence ontology is unlikely ever to become a medical specialty. It is not being that matters so much as doing. Perhaps this is why so much interpretative writing around medicine has accused physicians of a certain shallowness. The physician treats “disease,” these discourses complain, whereas the patient experiences “illness.” The specialist deals with one organ, system or dysfunction, thus “reducing” the patient to that organ, system or dysfunction. Patients adopt a “sick role” imposed upon them by social norms and medical authority. There is a deep and dualistic divide, as between body and soul.

Mol's innovation is to bypass these critiques. She eschews the whole business of “interpretation” by examining in concrete, empirical, ethnographic terms what happens in illness and its treatment. Her object is a certain category of being that we might call “that which is enacted.” She calls her work “praxiology” — the study of practices. This is hardly an approach that strains common sense, but it certainly strains language from time to time. Thus, Mol speaks not of “having” or “treating” atherosclerosis, but of patients and physicians “doing” atherosclerosis.

Mol's ethnographic method involved spending four years making visits once or twice a week to “a university hospital in a medium-sized town in the center of the Netherlands.” She calls it “hospital Z.” She talked to pathologists, hematologists and surgeons, observing them at work in the operating theatre, laboratory and consultation room. The modes of practice she describes all have their own, narrow focus, but are nonetheless many-layered and complex. The “miracle to explain,” Mol writes, “is how, even so, [they] somehow hang together.”

Mol's emphasis, ultimately, is on the interconnections within medicine's multiplicity. Some observations of a vascular surgery:

The resident is making the final sutures. The fasciae. The skin. While looking at his working hands, he continues the conversation he's having with the junior surgeon. This seems to be gossip about a nurse, a mutual friend, whoever: “She's a neat person, isn't she, I like her, you can laugh with her.” It takes me a few seconds to realize he's talking about the patient. (p. 124)

Physicians might feel flattered to be examined with such rapt and respectful attention. Whether Mol's observations will be obvious, or revelatory, to physician readers is hard for this reviewer to say. One might imagine that they will result in a somewhat weird self-recognition, like suddenly seeing oneself in a security monitor. But Mol's close observation does not amount to surveillance. Her motivations are not hostile, except perhaps, implicitly, toward the forms of poststructural analysis that cause meaning to crumble in the hands of the interpreter. Multiplicity is not chaos.

The multiplicity that Mol records is greater than the varying practices she observes between specialties in one hospital. Her limited observations in other institutions quickly led her to realize just how context-specific medical interventions are. “Ontology in medical practice is bound to a specific site and situation” (p. 53). This has implications for medical ethics, which in Mol's view can only be “enacted” in the specific details of each case. She does not seek universals. Moreover, unlike the health administrator or the writer of consensus guidelines, she is uninterested in generalizations and guidelines. Her subject is not “quality of care,” although in her last chapter she opens up the question of what it is to consider “the good” in medical practice.

In Mol's view, the reasoning typical of medical ethics posits a reality that is distinct from action, as if “values” (the province of the patient) existed in a realm separate from “facts” (the realm of the physician). She proposes another way of seeking the good in medical acts:

What if values reside inside the facts? Then it may be better to stop shifting the boundary between the domains of professionals and patients and instead look for new ways of governing the territory together. (p. 171)

It remains to be explained that The Body Multiple is in fact a double study. Mol's “main” text, her study of hospital Z, runs along the top two-thirds or so of each page. Running underneath is an articulate and challenging subtext, which one may read before, after, or concurrently with each chapter. In this subtext Mol examines her own writing against the background of other texts in the sociology of medicine, philosophy, gender studies, and health economics. Thus she situates herself methodologically and conceptually. This transparent declaration of position is rare in contemporary theoretical discourse and will be helpful to readers who are as curious about theory-making as Mol is about medicine.

Anne Marie Todkill CMAJ