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Ontologies for

Developing Things

Making Health Care Futures ThroughTechnology

Casper Bruun Jensen

S en s e Pub l i s h e r s

T R A N S D I S C I P L I N A R Y S T U D I E S



Ontologies for Developing Things



TRANSDISCIPLINARY STUDIES

Volume 03

Series editor Jeremy Hunsinger, University of Illinois, Chicago

Jason Nolan, Ryerson University, Toronto, Canada

Editor ial board

Megan Boler, University of Toronto, CanadaGeoffrey C. Bowker, Pittsburgh University, USA

Timothy W. Luke, Virginia Polytechnic Institute and State University Wendy Martin, Claremont Graduate School, USA Helga Nowotny, Wissenschaftszentrum Wien (Science Center Vienna), Austria

Joel Weiss, University of Toronto

Scope

Transdisciplinary Studies is an internationally oriented book series created to generatenew theories and practices to extricate transdisciplinary learning and research fromthe confining discourses of traditional disciplinarities. Within transdisciplinarydomains, this series publishes empirically grounded, theoretically sound work thatseeks to identify and solve global problems that conventional disciplinary perspectivescannot capture. Transdisciplinary Studies seeks to accentuate those aspects ofscholarly research which cut across today’s learned disciplines in an effort to define

the new axiologies and forms of praxis that are transforming contemporary learning.This series intends to promote a new appreciation for transdisciplinary research toaudiences that are seeking ways of understanding complex, global problems thatmany now realize disciplinary perspectives cannot fully address. Teachers, scholars, policy makers, educators and researchers working to address issues in technologystudies, education, public finance, discourse studies, professional ethics, politicalanalysis, learning, ecological systems, modern medicine, and other fields clearlyare ready to begin investing in transdisciplinary models of research. It is for thosemany different audiences in these diverse fields that we hope to reach, not merelywith topical research, but also through considering new epistemic and ontologicalfoundations for of transdisciplinary research. We hope this series will exemplifythe global transformations of education and learning across the disciplines for yearsto come.




Making Health Care Futures Through Technology

Casper Bruun Jensen IT University of Copenhagen, Denmark

SENSE PUBLISHERSROTTERDAM/BOSTON/TAIPEI



A C.I.P. record for this book is available from the Library of Congress.

ISBN: 978-94-6091-208-5 (paperback)ISBN: 978-94-6091-209-2 (hardback)ISBN: 978-94-6091-210-8 (e-book)

Published by: Sense Publishers,P.O. Box 21858,3001 AW Rotterdam,The Netherlands

http://www.sensepublishers.com

Printed on acid-free paper

The cover is an excerpt from the painting “Miscommunication” (2010) by Danish artistSanne Bruun Rosenmay (www.arterie.dk)

All Rights Reserved © 2010 Sense Publishers

No part of this work may be reproduced, stored in a retrieval system, or transmitted in anyform or by any means, electronic, mechanical, photocopying, microfilming, recording orotherwise, without written permission from the Publisher, with the exception of any materialsupplied specifically for the purpose of being entered and executed on a computer system,for exclusive use by the purchaser of the work.



v

TABLE OF CONTENTS

Acknowledgments and Reading Guide .................................................................. vii

Preface..................................................................................................................... xi

1. An Amodern Disposition: On Performativity, Practical Ontology,and Intervention................................................................................................... 1

2. Researching Partially Existing Objects: Ontologies for Developing Things..... 193. The Birth of a Future-Generating Device: On Electronic Patient Records

and Expectations................................................................................................ 31

4. Traveling Standards........................................................................................... 51

5. Citizen Projects and Consensus Building at the Danish Board ofTechnology: On Experiments in Democracy..................................................... 69

6. Infrastructural Fractals: Re-Visiting the Micro-Macro Distinction inSocial Theory..................................................................................................... 85

7. Sorting Attachments and the Multiplicity of Usefulness ................................. 101

8. Power, Technology and Medical Sociology: An Infrastructural Inversion ..... 119

9. Established Sentiments, Alternative Agendas, and Politics ofConcretization.................................................................................................. 137

Bibliography......................................................................................................... 157

Index .................................................................................................................... 169



vii

ACKNOWLEDGMENTS AND READING GUIDE

This book is the result of research that began while I was a Ph.D.-student at theDepartment of Information-and Media Studies at the University of Aarhus, Denmark between 2001–2004. Originally, Finn Olesen and Randi Markussen introduced meto science and technology studies and they, as well as, Andrew Pickering inspiredme to start these studies. And engagement with members of the emerging – nowflourishing – STS environment in Denmark, especially Peter Lauritsen, ChristopherGad, Brit Ross Winthereik and Signe Vikkelsø, continued to provide inspiration.

My philosophical interests were nourished as a visiting researcher at Don Ihde’s

Technoscience Research Seminar , at the State University of New York, Stony Brook,and in ongoing conversations with Evan M. Selinger. Later, my constructivisttendencies (and capabilities, such as they may be) were strengthened as a researchfellow at the Center for Interdisciplinary Studies in Science and Cultural Theory atDuke University, under the supervision of Barbara Herrnstein Smith and throughdiscussions with Geoffrey C. Bowker, Steven D. Brown and Isabelle Stengers.

One of the recurrent themes of the book is the normativity and politics ofconstructivist STS. This topic was the focus of two workshops, one in Amsterdam,one in Aarhus, and a special issue of Science as Culture that I organized and editedwith Teun Zuiderent-Jerak. I’d like to thank him, as well as the participants in the

workshops and Nina Boulus for their inputs and thoughts.Finally, I would like to thank Jeremy Hunsinger for his encouragement and the

staff at Sense Publishers for their assistance.Many chapters have been presented in different formats and to different audiences.

Chapter one “An Amodern Disposition: On Performativity, Practical Ontology,and Intervention” was originally published as “A Non-Humanist Disposition: OnPerformativity, Practical Ontology, and Intervention” in Configurations vol. 12.229–61, 2004. Reprinted by permission of The Johns Hopkins University Press.

Chapter two, “Researching Partially Existing Objects: Ontology for Developing

Things” was first published in the Center for STS-studies at the University ofAarhus working paper series no. 4. Reprinted by permission of the Center for STS-Studies at the University of Aarhus.

Chapter three “The Birth of a Future-Generating Device” was first presented as“An Experiment in Performative History: The Electronic Patient Record as a Future-Generating Device”, at the Public Proofs: Science, Technology and Democracy,4S/EASST 2004, Ecole des Mines de Paris, August 2004. It was published ina significantly different form as “An Experiment in Performative History: The DanishElectronic Patient Record as a Future-Generating Device.” Social Studies of Science. Vol. 35 No. 2, 241–67. 2005. Copyright © Sage Publications 2005, by Permission of

Sage Publications Ltd. The current version draws additionally on presentations madeat the conference for the Danish Association of Science and Technology Studies,Århus, June 2008 and at the 4S/EASST conference “Acting with Science, Technologyand Medicine”, Rotterdam, The Netherlands, August 2008.




viii

Chapter four “Traveling Standards” was presented as “The StandardisationDebates on Danish Electronic Patient Records: Handling a Differend in Practice”,

at the EASST 2002 conference “Responsibility Under Uncertainty”, Universityof York, UK, July 2002 and at the “Infrastructures for Digital Communication”graduate conference, University of California, San Diego, January 2003. It wasfirst published in the Center for STS-studies at the University of Aarhus working paper series no. 8. It is reprinted by permission of the Center for STS-Studies at theUniversity of Aarhus.

Chapter five on “Citizen Projects and Consensus-Building” was presented at theworkshop at Science Studies and Sociology, University of Madison, Wisconsin,February 2003 and at the workshop on “Technologies of Nature-Politics”, held at

the Center for Technology, Innovation and Culture, University of Oslo, February2006. It has been published as part of the EU-frame program STAGE inR. Hagendijk, P. Healey, M. Horst and A. Irwin (eds) Science, Technology and

Governance in Europe: Challenges of Public Engagement . Stage (EU FP5: contractHPSE-CT2001-50003) Final Report, February 2005 and in Acta Sociologica.

Special issue on Science, Power, and Democracy.Vol. 48 No. 3. 221–35. 2005.Copyright © Sage Publications 2005, by Permission of Sage Publications Ltd. “

Chapter six “Infrastructural Fractals” was first published “Infrastructural Fractals:Re-visiting the Micro-Macro Distinction in Social Theory.” Environment and

Planning D: Society and Space. Vol. 25 No. 5. 832–50. 2007. Reprinted by per-

mission of Pion Ltd, London.Chapter seven “Sorting Attachments and the Multiplicity of Usefulness”

integrates discussion from the paper “Sorting Attachments: On Interventions andUsefulness in STS and Health Policy,” Practices of Assessment and Intervention inAction-Oriented Science and Technology Studies, Amsterdam, April 2005 and published as “Sorting Attachments: Usefulness of STS in Health Care Practice andPolicy.” Science as Culture Vol. 16 No. 3 (Special issue: “Unpacking “Intervention”in Science and Technology Studies”. 237–53. 2007, reprinted by permission ofRoutledge, and the paper “Description as Inquiry and Experimentation: On theMultiplicity of Usefulness in/of Ethnographic Practice.” prepared for the “What isthe point of description” panel convened by Marilyn Strathern for the “Descriptionand creativity: Approaches to collaboration and value from anthropology, art,science, and technology” conference, King’s College, Cambridge, U.K., July 3–5,2005.

Chapter eight, “Power, Technology and Social Studies of Health Care: AnInfrastructural Inversion” was originally published in Health Care Analysis Vol. 16 No. 4. 155–74, 2008. It is reprinted with kind permission from Springer Science+Business Media.

Finally, chapter nine, “Established Sentiments, Alternative Agendas and Politics

of Concretization” was presented at the Department for the History of Conscious-ness, University of California, Santa Cruz. It was published in Configurations

Vol. 14 No. 3. 217–44. 2006. Reprinted by permission of the John HopkinsUniversity Press.




ix

The book is organized as follows: Chapter one provides an analytical backgroundand introduces several key concepts relating to ‘amodern’, ‘nonhumanist’ studies

of science and technology. Chapter two offers a brief (anti-)methodologicaldiscussion of how to study ‘ontologies for developing things’. Chapters three to sixare empirically oriented towards processes and controversies relating to thedevelopment of electronic patient records (EPRs) in Denmark. Chapter three givesa brief historical account of the EPR and analyzes the emergence of this technologyas a ‘future-generating device’. Chapter four considers questions of standardizationand their entwinement with social, political and economic issues. Chapter fivefollows the EPR as it became an object of democratic debate and inquiry at theDanish Board of Technology. Chapter six revisits some of the previously encounteredempirical scenes and offers an argument that the researcher might make bettersense of them by avoiding the loaded categories of micro- and macro-studies, insteadtracing ‘infrastructural fractals’. Chapter seven and eight are based on empiricalwork conducted at a Canadian hospital. In chapter seven I make use of experiencesas ‘action-oriented’ researcher in order to articulate the job of the contemporarysocial researchers as one of ‘sorting attachments’. This chapter critically engagesthe question of how STS (and other social sciences) might be ‘useful’ and ‘relevant’.Chapter eight uses material from a technology implementation project to considerthe role of power and its relation to technology in social studies of health care.Finally, chapter nine, offers a kind of incomplete synthesis of the main analyticalthemes that have run through the book. Rather than becoming useful or relevant, butalso instead of ‘criticizing the powerful’, or ‘giving voice’, the chapter argues thatstudies of ontologies for developing things, should be conducted in a way so as‘not to hinder becoming’.



xi

PREFACE

There is a certain genre of books that issue an ‘invitation’ to the reader to a particularfield or area of study. These ‘Invitation to X’ books promise to open up a hithertounexplored vista of learning. The author acts as a guide, or better yet as an insider,welcoming the reader into their inner circle: ‘stick with me kid, I’ll show youaround’. Invitations come, of course, with strings attached. To accept such aninvitation is to agree to the assumption that the author has a privileged perspective,that they can provide an overview of matters as they actually are from the perspective of those who are able to see them properly. Backstage: exclusive.

This book offers no such invitations. One of its central tenets is instead ‘no promises’. This is to say that whilst this is certainly an inviting text, whichwelcomes the reader into a habitable world, rich in possibilities, there is no pretence that this is a neutral guidebook for the perplexed. In part this is becausethe field which the author describes – Science and Technology Studies (STS) –does not really lend itself to rapid survey. Emerging from the ashes of the Sociologyof Scientific Knowledge, a discipline that now only exists in the kaleidoscopicafterlife given to it by Malcolm Ashmore’s The Reflexive Thesis, STS is the pointwhere philosophy, anthropology and sociology meet together in the shadow cast bythe exact sciences. As such, writing in the STS is typically a prime candidate for

what Marilyn Strathern refers to as ‘blurred genres’. Her contrast case, which thetext approvingly cites, is with ‘complex trajectories’. It is one of the manyaccomplishments of this book to exemplify this elusive distinction.

What STS lacks in terms of clear disciplinary foundations is more than made upfor by a certain kind of modishness. This is clearly evident in the work of the bestknown representative of STS, Bruno Latour, who is also one of the most renownedstylists in contemporary social science, and with whom a significant proportion ofthis book is both explicitly and implicitly in dialogue. Casper Bruun Jensen, too,demonstrates impeccably good taste and discernment in his choice and use oftheory. Readers in search of discussion around concepts-de-jour like ‘performativity’,

‘the turn to ontology’, ‘assemblages’, ‘cyborgs’ will find immediate gratification inwhat follows. But at the same time, the text is marked by a kind of classicism.Longstanding debates around the micro-macro distinction, the practicality ofsocial science as a vocation and the nature of power are revisited. This is donenot because the author promises – finally! – to offer a neat resolution, but becausethese debates take on a new tenor and importance in the course of following the particular objects and relations which form the bulk of the research in this text. Thetext is a sort of key change where the melodies of social scientific enquiry areintensified and refreshed.

It is traditional in social science to operate in a mode of ‘last person standing’.

One obliterates ones’ potential rivals and interlocutors as part of the ritual oflaying out the groundwork. This tendency towards ‘total critique’ makes for a goodspectacle, but perhaps not for a very satisfying resolution. There is very little blunderbuss critique on offer here. In fact, the text for the most part follows



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Isabelle Stengers’ call to ‘respect established sentiments’. This much misunderstood phrase makes it sound as though analysis ought to confine itself to commentary or

elaboration – in this case of current technological advances in public medicine. Butas Casper Bruun Jensen shows it is best understood as recognition that any criticalengagement with an object of study cannot begin with a questioning of its right toexist. Whatever our views might be of the viability or the ethics of an ElectronicPatient Record and with the rapidly advancing field of medical informatics, italready ‘is’, it has a concrete existence and set of capacities which are not negated by any supposedly critical discourse. The question is rather what can be connectedto (and indeed disconnected from) the mass of relations and actors for which theterm ‘electronic patient record’ is shorthand.

A rejection of total critique does not, however, mean a refusal to judge. Thereare incisive discussions of contemporary work and strong positions taken on whatit is to do STS in a ‘performative’ mode. Judgement and evaluation are not idlereflective matters but central to how this texts lives, how it breathes. If, as Latourdeclaims, ‘existence is action’, then for a text to exist it must endeavour to persistthrough selecting, connecting and acting in concert with the scholarly, professionaland public worlds into which it is cast. From a performative perspective, no text,no body, no actant can survive on its own. Its merits are to be judged on the basisof the particular kind of existence – which means a web of relations – it canfashion for itself.

Performativity is central to what Casper Bruun Jensen occasionally refers to as‘non-humanist’ STS. The choice of prefix is interesting. ‘Anti-humanism’, forexample, defines a critical attitude to the supposed legacy of the Europeanhumanist tradition. Whilst many of the writers discussed in the text have arelationship to this critical move, it does not figure as a substantive issue here.Similarly, ‘post-humanism’, concerns itself with the decidedly unnatural state ofthe human brought about by technological change. Again, despite strong affinitieswith the general shape of the argument, the text does not dwell on this oftenhackneyed debate. So why ‘non-humanism’? The term recognises that the humansubject no longer occupies what Foucault by way of Velasquez described as ‘the

place of the king’. It also takes for granted the interdependency between peopleand things. The difference concerns instead what follows from this recognition ofcomplexity. Questions of social justice, of creating and fostering liveable livesremain despite the lack of sovereign subject to whom these questions mighttypically be referred. Non-humanism then promotes the ethical and the evaluative,it asks which kinds of assemblies of relations between people and things we wishto support, what kinds of lives are worth living (where the category of ‘life’ is notreserved for humans alone). In this sense non-humanism might also be called‘alternate humanism’ insofar as it carries forward the experiential and emancipatorydynamic of humanism beyond its established confines.

Non-humanism is a practical matter. Drawing on the work of Isabelle Stengers,Casper Bruun Jensen uses the term ‘experiment’ to refer to the making and breaking of connections. In this sense any newly proposed arrangement of relations –such as that between patients, doctors, nurses and medical technologies – is an



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experiment, an attempt to explore what these actors can jointly do to and with oneanother when they are brought together. Make one further step: what the analyst

does is not so much describe an experiment, but add a further element to thatweave of relations. Description becomes part of the experiment, it opens it out ina further direction and expands further its capacity to connect. If this is so then the bar is raised for what counts as adequate description.

Gilbert Ryle famously demonstrated that in order to capture what is at stake inthe simple gesture of a winking eye a ‘thick description’ of the myriad socialrelations that might potentially be enacted in that moment was necessary. Ryle’sexample is properly philosophical in the sense that is concerns no-one in particularin a space outside of any definite cultural or historical location. When thickdescription is applied to actual empirical cases – as demonstrated by CliffordGeertz – the practical difficulties of this philosophical parlour game becomerapidly apparent. Just how thick should the description be? Where does one start?When can one stop? The task that STS scholars such as Casper Bruun Jensen setthemselves makes the questions even more urgent, since ‘the field’ they enter is nolonger clearly bounded by geography or by social relations. The electronic patientrecord is an actor (or rather endless strings of actors) that displays a kind oftopological complexity in terms of social relations. Social topologies, complextrajectories, technological realities and imaginaries: this is the stuff of STS.Amongst this shifting array of actors and actions one is hard pressed to locate the‘winking eye’ that can serve as cornerstone for analysis. What is done instead is to propose a variety of starting points. These are not chosen at random, but rathercarefully selected, or, we might say, ‘invented’, on the basis of sorts of connectionsand vectors they afford. The method is to always multiply and expand theempirical object, to treat it as a crystal which reproduces, but also complexifies itsstructure as it grows at its edges. In so doing analysis becomes one of those edges.The empirical object acts through the analysis, which becomes part of its existence.

In this book Casper Bruun Jensen does not just describe, he ‘winks back’ at thetechnologies engaged. He conducts analysis as though it were a process ofinvention, repeated over and again on the field until it grows connections on every

side. We might call this a work of ‘thick invention’. It is a set of experimentswhich thinks with and through its object, which seek to create a form of life with it.The book does not – it cannot – promise what the outcome will be. That is in ourhands as readers and fellow experimenters who can take and tinker with this finetext as we see fit.

Professor Steven D. Brown, University of Leicester, UK



1

CHAPTER 1

AN AMODERN DISPOSITION

On Performativity, Practical Ontology, and Intervention

How to turn an opposition into a possible matter of contrast? Obviously, thisis not only a question of goodwill. My guess is that we may do so through

the experimental extension of the specific risks that singularize each position.Giving a chance for contrasts to be created where oppositions rule implies producing a middle ground but not a medium or average mitigating differ-ences. It should be a middle ground for testing, in order that the contrastsevolve not from tamed differences but from creatively redefined ones. (Stengers,2002: 236–7)

Science and technology studies (STS) today can be viewed as a relatively stableenterprise, with its own conferences, journals, professional organizations, andgraduate programs. With Bruno Latour, one could talk about the black-boxing1

of STS. Yet, characterising a study as “in STS,” does not determine its featuresvery predictably because the field of inquiry, is heterogeneous as regards theassumptions, theories, institutional affiliations, methods, approaches, goals, andinterests of its practitioners. For this reason Michael Lynch and Kathleen Jordan’sterm “translucent box” is probably more fitting (Jordan and Lynch, 1992: 207; alsoRamsey, 1992: 284).

Undoubtedly, this diversity and differentiation makes any one description of STS problematic. As has been argued, disciplinary “looseness” is often an asset, ratherthan a weakness for developing disciplines and practices (e.g. Clarke and Fujimura,1992) that are inevitably shaped in the historically contingent interactions between

multiple kinds of actors with different agendas and aspirations. The gesture of presenting the chapters that follow as a “strong case” of STS, by emphasising thecoherent theoretical basis on which it is built thus reproduces an idea with whichSTS itself has regularly taken issue; that the unified position of a scientificcommunity is necessarily a measure of the epistemological merit of that community,and therefore conveys, or at least ought to convey, additional credibility to thestatements of its members.2

Rather than unification, several debates that may be observed within and aroundSTS bears resemblance to what Barbara Herrnstein Smith has called microdynamicsof incommensurability. Their familiar frustrations are exemplified as follows: “‘You

can’t argue with these people,’ says one. ‘They don’t play by the rules; theychallenge every word you say.’ ‘It’s like talking to a brick wall,’ says the other.‘They don’t hear a word you say; they keep repeating the same arguments’”(Smith, 1997: xii). Smith proposes that such stalemates are often not due to simple



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misunderstanding or to differences in vocabulary, but are rather symptomatic of“systematically interrelated divergences of conceptualization, that emerge at every

level and operate across an entire intellectual domain.” (Smith, 1997: 131).Within and around STS, such divergences display themselves with especial

vigor in relation to recently emerging agendas revolving around such notions as performativity and practical ontology, the activation of objects as nonhuman

actors, and questions relating to the politics, normativity, interventionism, activismand usefulness of the field. Put together, the performative and ontological re-orientation in the understanding of the content and stakes of STS can be seen ascharacterizing a “amodern” and “non-humanist” disposition (rather than an theory,for performative reasons, to which I will return); one which has been particularly(but not exclusively) inspired by post-structuralism and pragmatism.

Criticisms of various aspects of such a disposition have been expressed particularlyin terms of normative worries, and accusations of political abdication (e.g. Radder1998, Winner 1993, Woodhouse et al 2002). In view of such criticism, I believe animportant task lies in articulating the considerable potentials, in terms of bothalternative conceptualizations and interventions that amodern, nonhumanists STS mayhold for understanding the role of technology in contemporary health care organi-zations and in social life more broadly. This is a key issue in the following chapters.The aspiration to analyze these relations is captured in the book title Ontologies for

Developing Things, for reasons that will hopefully become clear. The analyticaldisposition underpinning this venture, and some of its theoretical implications, areoutlined in this chapter., which draws upon a range of ideas from writers such asDonna Haraway, Andrew Pickering, and Bruno Latour, which have various affinitieswith poststructuralists such as Gilles Deleuze, Michel Foucault and Michel Serres.

All of these people are not talking about precisely the same issues and they are notsaying exactly the same things; it is not, therefore, my interest to try to integrate all ofthem in a common, eclectic framework. Instead, I take my cue from philosopher ofscience Isabelle Stengers who, in the introductory citation, wonders about how to turndifferences or, indeed, antagonistic oppositions into productive intellectual contrasts.And she suggests that a solution could be found in experimentally processing sets of

positions through each other. Productivity would be created at the middle-ground,where no position would be able to silence any other, and where differences wouldtherefore have to be respected, rather than made to disappear (either by force or byconsensus; which is often a more invidious force since it is rarely recognized as such).

The latter qualification is important, because it emphasizes that tolerance ofalternative perspectives is not necessarily, certainly not always, the ideal. Speci-fically, it means that in the following I am not prevented from noting and, indeed,going some lengths to stress ‘amodern disagreements’ with a number of positionswithin STS and more broadly. This is due to the assumption that it is only by painstakingly working to clarify differences, rather than glossing them in the name of

a pluralistic “good-will” that a serious evaluation of the possibilities, limits, andimplications of amodern STS-studies can be attempted.In what follows, I concentrate in particular on the shift from a representational

to a performative idiom for analyzing scientific and technological processes, and



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ideas are generated in the interaction with obdurate materials with unknown qualities,and for this reason a prominent concern of epistemology has been with purifying

science from the many biases that could potentially invalidate its knowledge in thisinteraction. Epistemology thus tries to establish an ideal relationship between thelevel of scientific ideas and the level of their practical validation and application, andin this project it has consistently prioritized theory over practice. In contemporaryepistemology this purification has been typically managed by invocation of thescientific method, which, if properly applied, has been seen as the guarantee ofknowledge claims. In recent years claims pertaining to the absoluteness or univer-sality of such claims have been toned down somewhat, and often the emphasis is nowon securing the least fallible knowledge. Yet, the claim to be able to (unequivocally)determine what is least fallible continues to rely on an idea of an external standard,which allows one to measure and determine which kinds of knowledge are more andless secure.

The classical epistemological ambition is regularly presented as a defence againstthe contamination of knowledge claims, for instance by the partisanship or local provincialism of their producers. The analytic philosopher Paul Boghossian, in a recent polemic against constructivism in general and Barbara Herrnstein Smith in particular (one, which, incidentally, vividly illustrates Smith’s analysis of micro-dynamics of incommensurability), offers the following description:

What matters to epistemology are three things: first, the claim that only some

considerations can genuinely justify a belief, namely, those that bear on itstruth, second, a substantive conception of the sorts of considerations thatquality for this normative status—observational evidence and logic, forexample, but not a person’s political commitments; and finally, the claim thatwe do sometimes believe something because there are considerations that justify it and not as a result of some other cause, such as because it wouldserve our interests to do so (Boghossian, 2002: 218)

Another example is afforded by John Searle’s The Construction of Social Reality,which has less interest in defending epistemology per se, yet leaves no doubt aboutthe undiminished importance of such classical notions as evidence, objectivity,reality, and truth:

Having knowledge consists in having true representations for which we cangive certain sorts of justification or evidence. Knowledge is thus by definitionobjective in the epistemic sense, because the criteria for knowledge are notarbitrary, and they are impersonal (Searle, 1995: 151).

Undoubtedly the understanding of what exactly counts as proper evidence, objectivityand truth varies between analytic philosophers, including Boghossian and Searle, asdoes, therefore, interpretations of what the scientific method would consist in, andhow to properly make use of it. Certainly, analytic philosophers would also contend

that the differences between the positions of Boghossian and Searle are substantial.However, what remains in the background of these debates is the assumption

that traditional notions of evidence, objectivity, reality, and truth cannot be donewithout; not, at least, without inviting epistemological catastrophe. The challenge




5

posed to classical epistemology by STS-research has therefore been much moresevere than internal epistemological quarrels. For in insisting on the participation

of practical and material effects in the production of knowledge, these studies have problematized many of the key-distinctions and relations in epistemology; notably between knowledge and power and between (scientific) ideas and their (technical)concretizations. By doing so they have ineluctably challenged the central episte-mological ambition to guarantee the possibility of formulating true, in the sense ofreliably decontextualized, statements about the world. This challenge of construc-tivism is of wide-ranging ramifications for the conceptualization of science,technology, society and their interrelationships and, in this context, for articulatingontologies for developing things.

PRINCIPLES OF SYMMETRY

These ramifications are themselves variably reviewed depending upon the strandof STS-studies of one’s adherence (such as, for instance, standpoint feminism,sociology of scientific knowledge, social epistemology, symbolic interactionism,cultural anthropological studies of science or actor-network theory). Many of thesestudies would in principle agree with the famous symmetry doctrine, formulated bysociologist of science David Bloor, which proposes that statements that we take to be true and statements that we take to be false should be accounted for with thesame set of explanatory devices (Bloor, 1976: 243). But what is viewed as following

from this doctrine is highly variable.Michel Callon and Bruno Latour accepted the general outline of Bloorian

symmetry but extended, or generalized it (Callon, 1986; Callon and Latour 1992).Their suggestion was that, as well as symmetry between the truth or falsehood ofstatements, analysts need to be symmetrical with respect to the question of who

acts in shaping the world. Famously, their suggestion was that not only humansact. It is as often the case that humans are acted on by other – nonhuman – actors.If this is the case the aspiration to offer a sociological analysis of science andtechnology is limiting, since society can offer no stable explanatory framework forscientific and technological development. Instead, generalized symmetry posits a

situation in which society and nature is constructed in the same process. Contraryto what is sometimes imputed this has nothing to do with arguing that humans andtechnologies are somehow ‘the same’. Instead, generalized symmetry can be viewedas a methodical insurance policy against taking for granted any preconceived notionof who has the power to act. It thus multiplies the potentially relevant actors andforce attention on their differences and relations. The aspiration is to thereby facilitatemore nuanced analyses of how humans and things (broadly construed) togethercreate, stabilized and change worlds. Analyses, in other words, that are sensitive tohuman and nonhuman activities as practical ontology: efforts to concretely shapeand interrelate the components that make up the worlds they inhabit.

Of course, general symmetry and its implied “turn to ontology” has not goneunchallenged. In the famous “chicken debate” between sociologists of scienceHarry Collins and Steven Yearley, reflexivist Steve Woolgar, and actor-networktheorists Bruno Latour and Michel Callon, the former formulated one important



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version of the consequences of adopting a constructivist stance in the explorationof science. Collins and Yearley suggested a dualistic model, referred to as meta-

alternation, in order to account for how one could take seriously both the realistfindings of scientific research and the constructivist findings of science studiesresearch. The idea was that the sociologist (“promiscuously”) “develops the abilityto switch between different frames of reference,” viewing each setting as displaying but “one set of beliefs among many.” (Collins and Yearley 1992: 301). Yet, accordingto Collins and Yearley, this was a merely analytical stance, for one cannot, presumably, be a constructivist in everyday life:

In spite of this achievement, all of us, however sophisticated, can switch tomodes of knowing that allow us to catch buses and hold mortgages. We all

engage as a matter of fact in which we might call “meta-alternation (302)According to Collins and Yearley one necessarily ceases to be a social constructivistthe moment one enters the bus or pays mortgages, because one cannot doubt that itwill safely carry one home from work. While social constructivism as intellectual

endeavour is aligned with doubt and illusion (its job being to “pull the veil fromscience”) one must be a realist in everyday life, and especially so with respect toobjects of scientific inquiry.

The stance of meta-alternation was defined in part to discredit the actor-networkidea that non-human things such as scallops should be “granted agency.” It enabled

Collins and Yearley to query how one could really acquire knowledge of non-human capacities, and it suggested that one could not, except by becoming ascientist:

In any case, the complicity of the scallops (or whatever), if it is to play a partin accounts of this sort, ought to be properly recorded. How is the complicityof scallops to be measured? There is only one way we know of measuring thecomplicity of scallops, and that is by appropriate scientific research. If we arereally to enter scallop behavior into our explanatory equations, then Callonmust demonstrate his scientific credentials. He must show that he has a firmgrip on the nature of scallops. There is not the slightest reason for us to

accept his opinions on the nature of scallops if he is any less than a scallopexpert than the researchers he describes. In fact, we readers would prefer himto be more of a scallop expert than the others if he is to speak authoritativelyon the subject (316)

In matters scientific, we have no better bet than taking at face value the pronounce-ments of experts since they, but not we, are the specialists in their respective areas.All this sounds quite humble. However, when it comes to explaining the means ofachieving agreement on scientific matters, authority should be deferred to thesociologist of science, since this is his area of expertise. This model thus gives to

the scientist with the one hand the epistemic authority (realism about non-humans),which it seeks to remove with the other (constructivism about scientists’ realismabout non-humans). On the one hand the epistemological realist position of scienceis granted, but it is then doubled by the position of the sociologist, who is able to




7

show how realism is really the result of the open and negotiable work of scientists(but not of the open and negotiable work of natural entities). Although Collins and

Yearley conclude that “Of course we cannot claim epistemological authorityeither….We can only compete on even terms for our share of the world with all theusual weapons,” (324) this share takes on significant proportions, as the final say inepistemic matters is conferred back to the sociologist who really knows howscience works.

Similar double-movements of endorsing radical (anti-)epistemological principleswhile refraining to acknowledge their implications at the time when they wouldapply to one-self, a strategy which Barbara Herrnstein Smith has referred to as“cutting-edge equivocation,” (Smith, 2002) are found in a number of STS-studiesthat claim to offer specific kinds of political leverage in their engagements withtechnological practices, such as the ability to criticize or resist the status quo. It isthus worthwhile considering in more detail what are the critical or politicalimplications of general symmetry. To do so it is necessary to take a closer look atthe relation between performativity and practical ontology.

FROM EPISTEMOLOGY AND REPRESENTATION TO PRACTICAL ONTOLOGYAND PERFORMATIVITY

In the view here presented – and worked with in subsequent chapters – it will besuggested that the challenge of generalized symmetry is intimately bound up witha move from an epistemological approach to one focusing on practical ontology, andfrom a representational to a performative idiom in the understanding of science. Thegist of this change can be nicely summarized in a formulation of Bruno Latour,“ Essence is Existence and Existence is Action,” (Latour, 1999: 179) but its philo-sophical history can be traced, at least in some of their interpretations, to Greek philosophers such as Heraclitus and Lucretius, to Leibniz and Spinoza, to Friedrich Nietzsche and A. N. Whitehead and, unsurprisingly, to different radical thinkers inrecent French philosophy who, in effect, have worked to re-interpret several of theabove-mentioned; I think here in particular of Gilles Deleuze (1983, 1990, 1993),Michel Foucault (1984, 1984a), and Michel Serres (1982, 2000).

Essence is Existence. This is a claim which denies the purity of the ideal andrefers all there is, in the first instance, to the material world. Existence is Action.But what exists? We do not know, at least not comprehensively, or not yet. But whatthis formulation suggests is that we can try to find out; for, often enough, action andactivity is empirically observable. Not, however, as something simply out there. Foras scientists well know it is only through an organized and co-ordinated effort, usingmultiple machines and other things as mediators, that different entities become ableto reliably “express themselves.” The enabling by humans of such “expressivedisplays” can be characterized as “events” because of their unforeseeable character.4

The implication of this view is that novel aspects of the world (in the shape, forinstance, of new effects, particles, or phenomena) can be articulated in the laboratoryonly because of the constellation of the particular forces that constitute the givenexperiment by which they are shaped and through which they emerge. As such



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articulation takes place at the intersection of the (sets of ) forces, which we regularlycategorize as “observers,” “instruments,” and “the natural world,” the distinctions

among these forces and the properties that go with them themselves become problematic and are turned into topics for investigation, rather than taken forgranted as resources in the investigation of science and technology.

We have returned to the issue of generalized symmetry, for the implication ofthe discussion above is that STS needs to develop models and concepts to accountfor the fact that there are large differences between the effects of beliefs. In Callonand Latour’s original formulations, the stabilization (legitimation, institutionalisation)of some set of beliefs and practices rather than others is crucially dependent on thesuccessful delegation of actions and responsibilities to non-human actors, and theirconsequent practical re-definitions or translations. This move is related to AndrewPickering’s suggested emphasis on the performative dimension of science. As heexplains, “the representational idiom casts science as, above all, an activity thatmaps, mirrors, or corresponds to how the world really is” (Pickering, 1995: 5). But,Pickering continues, “there is quite another way of thinking about science;” one,which starts from the idea that the world is doing things, and is therefore, first ofall, full of agency. This idea is the starting point for a performative analysis ofscientific practice, “in which science is regarded a field of powers, capacities, and performances, situated in machinic captures of material agency.” (7).

For some time researchers in cultural studies, social anthropology, and qualitativesociology have told sophisticated stories about the artful work needed to successfullyintegrate the many different and sometimes contradictory exigencies of stabilizingsocial identities in multiple technologically mediated formations. In recent yearsthese stories have been extended to also cover the social formations involved intechno-scientific production, and this has been one important strand in the depurifica-tion of contemporary understandings of science. But what happens when non-humansare added to the collectives to be described?

Perhaps a first experience is one of increased complexity. Indeed, in someresearch in cultural studies and STS the delight in making visible complexity seemsto overshadow the question of what productive differences such re-description could

render pertinent. Another perspective would view the notion of complexity as a“lure for feeling”, with the capability of generating new, different and, perhaps,harder questions for us to answer about sciences and society. This is the proposalof Isabelle Stengers:

As for the notion of complexity, it sets out problems – we don’t know a prioriwhat “ sum of parts” means – and this problem implies that we cannot treat,under the pretext that they have the same “ parts,” all the “ sums” according tothe same general method (Stengers, 1997: 12–3)

In her suggestion, noticing complexity is the mere beginning of the process of

understanding and transforming relations between the sciences and society. It isa necessary beginning, however, because relevant questions regarding a givensituation can only be formulated if the situation has first been de-composed intoenough divergent elements to prevent its simple evaluation.




9

POWER AND COALITIONS

Today, most technological-social innovations affect things in much morevaried modes than those anticipated by our questions, and thus create a gap between “things,” as they are implicated in it, and their scientific representation (Stengers, 2000: 158)

Surely a lesson that has been well learned in the past century is that scientificinnovations are effective in a multiplicity of ways, only a small number of whichare anticipated (Fortun, 2001; Mackenzie, 1990; Perrow, 1999). Stengers is not thefirst, or only, scholar to point to the fact. In the domain of the “human sciences,”for instance, Michel Foucault, analyzed and described the multiple socio-politicaleffects, for better and worse, of the invention of modern medicine, psychiatry, andcriminology (e.g. Foucault, 1973, 1991). In this work he has pre-figured, as well asfunctioned as a tremendous inspiration for, research in STS and numerous otherdisciplines. In order to take up the challenge of Isabelle Stengers; how to respondinventively to the fact that non-human actors are increasingly brought to bear onour lives in ways we not only do not, but probably cannot anticipate, some ofFoucault’s sociopolitical ideas could prove useful.

Foucault’s political thinking was concerned, among other things, with how to“cut off the king’s head,” (Foucault, 2001: 121) by which he meant constructinga mode of political analysis, which would not primarily be organized about the

classical themes of sovereignty and law, and which would consequently not have toimagine that power comes “from above.”5 Instead he would be interested in the“play of power” as instantiated in myriad microprocesses throughout the socialfield. In different analyses Foucault showed how sets of practices were slowly and painstakingly composed, not least through the stabilization of specific discourses,even though no common interests between their constituents existed prior to theirengagements. Power (as efficacy of action) seemed thus not to be inherent in someactors (and not others), but rather to be always in the making. By consideringsocio-politics from this transformative viewpoint; as having to do with thecomposition of coalitions out of heterogeneous elements, rather than as having to

do with stable formations with specific pre-defined interests and powers, Foucaultcould view the construction of disciplinary and institutional matrices as “intentional but non-subjective,” rather than enforced by the presumptively powerful (Foucault,1990, esp. chapter two).

This conclusion, based in historical analysis, also functioned as a practicalheuristics in Foucault’s own political engagements. Since, in Foucault’s phrase“power is everywhere,” but inherently unstable and transformative (as it is shapedin the ongoing interactions between practices, discourses, institutions etc.) to resistspecific functions of power, one must become as flexible as it is. In this case, whatcould be termed roughly as a coalition-based approach to political action makes

sense, precisely because it is based on constellations of people, which temporarilytake shape around a cause of concern.6 As no overall political programme needs to be constructed for there to be resistance, no heavy bureaucratic apparatus mimicking

power would be needed to oppose it .7



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The Foucaultian (and Nietzschean) conception of power and the conditions for political efficacy has been theoretically developed in political theory by scholars

such as Ernesto Laclau and Chantal Mouffe’s influential work (1985), WendyBrown (1995, 2001) and by Judith Butler (1997). It has also been investigated inSTS through studies such as Steven Epstein’s (1996) on gay activism that shapedand redefined AIDS-research, Andrew Barry’s work on ecological activism (e.g.2001), and Brian Wynne’s (1996) writing on controversies between sheep farmersand scientists.

CO-ORDINATING SCIENCE, TECHNOLOGY AND SOCIETY

In the above examples I have focused on coalitions seemingly external to normalscience which took shape through efforts to resist specific kinds of development, but this should not be viewed simply as a matter of “outside forces” trying to“influence” what is (or ought to be) “internal” to science. For one point in re-describing scientific controversies in the language of shaping and transformingcoalitions is precisely to point to the fact that society is never external to scienceand technology. On the contrary the success of activists in challenging andredefining, for example, AIDS research can be seen as one more bridge being built between the presumed insides and outsides of science. If this is a (partial) successstory it is for the double reason that the articulation of parts of the AIDS researchcommunity with the agenda of activists simultaneously improved the situation of both communities: it enabled the scientists to do better science and improved on thelives and the chances of surviving for people with AIDS.8

However, successfully linking these “outsides” and “insides” is a difficult task, because the sets of practices, relevancies, and interests of those who would needto co-operate are often vastly divergent. As the articulation of a novel entity ina laboratory can be described as an event, so can the (partial) success of the AIDS-coalition in re-defining the relationship between science and the public, and for thesame reason; that it required a unique constellation of forces, which, far from being

given, had to be painstakingly constructed in order to “express itself ” effectively.

Such technoscientific events can be characterized as experiments in democracywhen they succeed in conferring on all interested parties the capacity of expressinga viewpoint, without trying to predetermine what it is, or what the consequences ofit should be (see chapter five).

STS-studies in various instantiations have been interested in analyzing how thecreative potential of scientific practices is opened up precisely to the extent thatideas, programmes, or techniques have had to be shared among what proto-STSscholar Ludwik Fleck referred to as different thought collectives with differentthought styles (Fleck, 1979; Smith, 1999). Scholars such as Leigh Star and JamesGriesemer (1989) have shown how the co-ordination of complicated scientific

efforts is not only not dependent on homogeneous interests among participants, butthat actors’ disparate goals may actually enable scientific success. In their work,they show how material entities can function as boundary objects that give just

enough structure to the interactions between members from heterogeneous social




11

worlds (or thought collectives) to enable the successful co-ordination of theirefforts, but does not try to impose on members the same definition of the work they

are trying to accomplish. It is the mediation of non-human actors that allowmembers of different social worlds to productively articulate their similarities anddissimilarities.

THE COLLAPSE OF EPISTEMOLOGY INTO ONTOLOGY

Stressing the intertwinement of human and non-human actors in science challengestraditional epistemology because activities such as observing or representingare not seen as distinct from intervening or constructing; rather they are viewedas specific ways of intervening and constructing (e.g. Hacking, 1983). In thisview epistemology collapses into ontology and the sciences are reformulated as practical activities aimed at (re-)building the world by adding new elements withnew capabilities and new relationships to it. Knowing (and thinking aboutknowing) is turned into particular styles and methods for connecting and co-operating with specific actors (human and otherwise), thus shaping reality, ordoing practical ontology. Scholars such as Annemarie Mol (2002), Hans-JörgRheinberger (1997), Charis Thompson (2005), and Helen Verran (2002) havedetailed this occurrence in various settings, and Latour has formulated the importantimplication: “There is no primary quality, no scientist can be reductionist,disciplines can only add to the world and almost never subtract from it.” (Latour,2004: 226).

This idea is almost as foreign to social constructivism as it is to epistemology because its focus is on the eventful reconfiguration of reality, taking place inlaboratories and elsewhere, rather than on the replacement of naturalist explanations of science with social or cultural ones.

The move, suggested in the Callon and Latour’s notion of generalized symmetry,of treating the sociality and the naturalness of the sciences as equally troublesome,thus opens up a space for viewing the sciences as vehicles for the construction ofmany different socionatural entities; for a multinaturalism replacing both (traditional,

realist) mononaturalism and multiculturalism (Viveiros de Castro, 2004; Latour,2004a). This position clearly leaves no room for the epistemological aspiration todefine a method for the generation of objective knowledge within a discipline,much less in general, because knowledge is constructed precisely at the intersectionof the many different agencies concretely interacting in the world. This conditionof specificity, of course, does not prevent technoscientific constructions from becoming consequential in different places or on quite different scales “in thehands of later users.”

THE “NORTH-WEST PASSAGE”: ORDERS, AND THEIR OTHERS

Michel Serres has provided a nice analogy for knowledge-production by comparingit to the famous navigational problem posed by the “Northwest passage” (Serresand Latour, 1995: 104, 152).9 Travelling the Northwest passage has many hazards



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such as wild tempests and drifting ice-floes but if these perilous conditions can besuccessfully navigated, novelty awaits at the end of the journey in the shape of a novel

(and usually unexpected) environment.In spite of the connotations of scientific heroism that this image may evoke, I do

not think glorification is the main point Serres is trying to make. It is possibleinstead to make some different observations. First, Serres, as Whitehead beforehim, presents a view of science as an adventurous journey in which curiosity and

jouissance figure as important components. But it is a journey with specific risksand dangers. This is not a very esoteric observation, but one to which people asdiverse as Cumbrian sheep-farmers, ACT-Up AIDS-Activists and Danish healthcare workers can testify. Since we really do not know how the landscape weencounter at the end of our journeys will look, this poses to scientists the importantchallenge of learning how to become responsible for all the entities of our making,which, nevertheless, “we are not mastering.” (Stengers, 2000a). Likewise, it posesto our societies and institution the challenge of learning how to respondinnovatively to the world-building activities of scientists, technologists andothers. This is the point at which politics, or critique, in another key, might be brought back into non-humanist, amodern analysis (see chapters 5, 6, 8 and 9).

Two additional points can be made. Throughout the Serresian sea-journey disorderand uncertainty reigns, and multiple contingencies must be handled to prevent the shipfrom perishing. Only at the end of the trip does it make sense to credit the travellerwith the courage and rationality necessary for its completion.10 But the ordering thusachieved also comes with a price, which is often forgotten; that the traveller is still

somewhere particular (albeit somewhere new) and for that reason not everywhere

else. As a metaphor for scientific work, this indicates that, contrary to commonviews, the scientific journey does not finally remove one from earth, providing accessto a non-situated and objective truth (Haraway’s “view from nowhere”). Insteadscience provides situated ways of knowing, which are always relying on specific, practical, institutional and conceptual orderings, which always come packaged withtheir own disorders; for example, their forgotten questions, perceived irrelevancies,impracticalities and other invisibilities that sociologists Marc Berg and Stefan

Timmermans (2000) have referred to as “orders and their others”, and that philosopherAdrian Cussins (1992) has pointed to in his theory of cognitive trails. This view thusreturns technoscientific endeavours to earth. It does not do so, however, with primaryambition of critiquing or denouncing. Rather it rather aims to reorient the normative potentials of STS as resolutely relational and symmetrical.

INTERVENTIONS AND INCOMMENSURABILITIES

Can one be unhappy with aspects of the world and seriously want to change it,while at the same time denying the (received) grounds for critique? This, ofcourse, has been strenuously denied by the vast majority of philosophers andother scholars over the last two thousand years, and is currently signalled by theimpotence and vague (or blatant) heresy ascribed to researchers that can betermed “relativist.” As Barbara Herrnstein Smith documents, even fairly radicalsuch scholars regularly feel the need to defend themselves against these accusations,




13

usually by claiming to “steer between” the dangers of some “naïve” orthodoxy andan “extreme” relativism, often characterized as “Scylla and Charybdis” (Smith, 2002

and see discussion in chapther nine).Actor-network theory and generalized symmetry has often been viewed as

particularly lacking in normativity. Even sophisticated and friendly-minded scholarsas Malcolm Ashmore find the Latourian strategy difficult to understand:

For infrareflexive [one of Latour’s term for his non-critical style of conductingscience studies] writing, on the other hand, you “just offer the lived world andwrite” (1988: 70). The necessary reflexivity is achieved by applying “principlesof analysis which are self-exemplifying” (1988: 171), by multiplying genres, by getting on the side of the known (1988: 173), by gaining explanatory

equality with those we study, and by refusing to build a metalanguage(1988: 174). It would really be very simple if it wasn’t quite impossible. As“a story, just another story” (1988: 171) Latour’s tale of infrareflexivity isa romance; and I’ve seldom read a better one. (Ashmore, 1989: 60)

Many other criticisms have been considerably less benign (e.g. Cohen, 1999).Critically minded scholars have repeatedly, and repetitiously, pointed to the presumed complicity of amodern thinking, with its Machiavellian bent, to its seeminglack of concern for properly emancipatory projects, such as feminism or Marxism.

The move is double. On the one hand amodern, nonhumanist studies are criticized

for being too critical of established categories, in their insistence on using a “flattenedontology” where things and people, social and natural entities, institutions andmicrobes are treated as analytically symmetrical. When such agnosticism perplexesor infuriates critics it is in part because it works to deprive them of the conceptualtools with which they achieve their critical effects. But if Latour and his colleaguesare viewed as too critical in their denunciation of modern categories, this is seen asmaking them too uncritical in not drawing the usual (foregone) critical conclusions.For the focus on the specificity of situations (“throw-away explanations”) and on thetransformative capacities of all involved actors prevents these researchers from pronouncing at the end of their stories on who were really the bad guys. Why and

how is this a problem?I would suggest that the stance of general symmetry remains impossible to

understand precisely to the extent that one situates oneself as (or akin to) a criticalepistemologist, trying to adequately represent the situation under investigation.With this disposition it will seem seems obvious that Latour’s presentations areselective, and to the extent that they do not match the preferences of the reader,criticism will be easily enabled (as, indeed, criticism is always easily enabled fromsuch a vantage point). In a performative understanding, however, the situation isquite different, as the researcher is, first and foremost, a participant, with all the problems this involves. For the critical stance, the first of these is that it becomes

impossible to claim for oneself a moral high ground. Or, rather, in a flattenedlandscape it is possible to exactly the same extent as it is to everyone else. To thesame extent, however, is not good enough if one wants one’s critical perspective to

get an edge over other positions.11



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This is where the idea of strategic essentialism (or differently named relatives ofthis idea) is often invoked;12 that is, the theoretically informed decision that atcertain points one should cling to ideas otherwise acknowledged as analyticallycrude, or even fictive, because it is viewed “strategically” as offering betteropportunities for practically engaging in “the real world” than sticking to one’smore subtle actual beliefs.13

It can be questioned, however, whether the adoption of various essentializedconcepts provides for adequate intellectual, political or practical responses andsolutions to the multitude of challenges facing the world today. It might even beargued that this strategy is politically irresponsible in its own way. In The Differend Jean-François Lyotard showed in detail that “a universal rule of judgment betweenheterogeneous genres is lacking in general.” (Lyotard, 1988: xi). Eduardo Viveirosde Castro has extended and redefined the challenge posed by this statement, bylocating it at the level of ontology involving the mutual existence of potentiallyincompatible natures, rather than at the level of representation and discourse. Thecrucial point of the differend is to emphasize how discursive genres may functionin resolutely divergent ways, providing no position from which to formulate anexternal evaluative measure. Hence, the possibility of discursive as well asontological incommensurability remains the background for intellectual and political work. In Barbara Herrnstein Smith’s words the implication is that:

The resounding reaffirmation of an absolute distinction between truth and

rhetoric, fact and fiction, science and superstition, will not in itself do thecrucial substantive, technical and often arduous work of effectively differen-tiating among specific competing, conflicting claims of truth or betweenmutual charges of falsehood. Nor will a general affirmation of the inestimablevalue, irrefutable possibility, and transcendent ideality of genuine objectivityidentify where, in any particular instance, objectivity lies – or (the pun is aptenough) “lies.” (Smith, 1997: 29–30)

PARTICIPATIONS

In view of everything said above it should be clear that I do not believe any generalmethod for solving the political and practical problems posed by reconceivingintellectual activity in the mode of performative nonhumanism. Nor, I think, wouldmy affirmation of such a method solve the issue; since, indeed, many other peoplehave already proposed many analyses, methods, criticisms, rebuttals, rules andguidelines without much luck. But, of course, this does not prevent me from takinga position on the matter and offering what I think is adequate reasons formaintaining it. I do, however, believe that the performative approaches outlinedabove offer better tools for making sense of the multitude of complex issues that

contemporary STS researchers are likely to get involved in, than presentlyavailable alternatives. In my estimation this is one way of achieving what Latourreferred to as “getting explanatory equality,” both with other researchers and withthose under study.




15

In fact, I think the dictum of explanatory equality is liberating. It liberates theresearcher from the belief that there is a specific set of ways by which one can

properly engage in research, and a determinable set of proper outcomes of such enga-gements (Jensen and Lauritsen, 2005). Both of these assumptions are, in my experi-ence, continually falsified in practice. The suspension of explanatory categories alongwith the urge to critique enables different research strategies, and modes of inter-action to be tested with our research subjects, those about whom we talk as scholars.In particular it forces us to learn to respond more keenly to what is going on in the

field , because we know that our explanations and interventions have to be renewed ineach instance. Our research agendas are therefore invariably, and perhaps increa-singly, shaped in ongoing engagements with the field. I think a similar idea is implied by Annemarie Mol’s phrase empirical philosophy, which she describes as follows:

It is possible to refrain from understanding objects as the central points offocus of different people’s perspectives. It is possible to understand theminstead 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 … Attending to the multiplicityof reality opens up the possibility of studying this remarkable achievement(Mol, 2002: 4–5)

Being able to follow this “remarkable achievement” does not give the researcher

any critical edge in the classical sense of being able to tell what is wrong , and whatconsequently ought to be done about it. But, arguably, this becomes less important, because amodern analyses bring with them an automatic unsettling effect , whichmay have numerous practical ramifications (see also chapter seven). Under suchre-description, practices and materialities, their inhabitants and their relationshipsstart to look different. Good examples include the work of both Marilyn Strathernand Michel Callon and Bruno Latour to re-figure the classical micro-macrodistinction in social theory (Callon and Latour, 1981; Strathern, 1991, and chaptersix) The former accomplishes such a shift by understanding social relationships asfractal, the latter by viewing the presumed macro-actors as micro-actors situated

“on top of many (leaky) black-boxes,” (Callon and Latour, 1981: 286) containingmore or less stabilized associations between human and non-human actors.Providing such alternative descriptions to people, both in and outside science and

technology studies, can be seen in itself as an intervention, possibly (although, ofcourse, not certainly) enabling these people to respond differently to their variousenvironments (see e.g. chapter five and seven). Although the specifics of this responsecannot be controlled by (and in) theory, I think this is already quite an achievement.

The effect of nonhumanist a-critical STS-studies, like everything else, wouldthen be in the hands of later users. These might be scholars or researchers, or theymight be “informants,” the old term for the co-producers of the research object.

Both of these groups are audiences whose responses to our texts, as they wereconceived, produced, and, finally, presented, will have also shaped the way thesetexts ended up looking. Assuredly, they are also audiences whose engagementswith our texts are highly variable.



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The continual and dynamic relationship between our own interests and those weencounter, as exemplified by the above-mentioned readers/co-producers of our

texts, is very nicely captured, I think, with Gilles Deleuze’s term, the powers of the false. Deleuze says:

A new status of narration follows from this: narration ceases to be truthful,that is, to claim to be true, and becomes fundamentally falsifying. This is notat all a case of “each has its own truth,” a variability of content. It is a powerof the false, which replaces and supersedes the form of the true, because it poses the problem of incompossible presents, or the co-existence of not-necessarily true pasts (Deleuze, 1989: 131)

The falsity here mentioned is not opposed to truth, as in the classical opposition;

for as in other theories I have discussed at length above, to Deleuze this notion oftruth (as universal, de-contextual, etc.) is exceedingly dubious. His playful invocationof falsity therefore at most suggests that if the standard of evaluation is classicaltruth then we would all be falsifiers. However, since a standard theory of truth is,in fact, not invoked , the powers of the false signals rather an opening up towards

collective explorations of situations that are both important and complex, sinceno-one can claim immediate access to their solution (situations, therefore, of“explanatory equality”) (see chapter five for further discussion on this).

I think the image of our work and texts as participating in the powers of the false

is a good one, but not a simple or gratuitous one. It is not simple and gratuitous

because no one has promised us anything .14 First, no one has promised us thatanyone will indeed become interested in our ideas, plans, or articulations; that wewill be able to make them resonate with those with whom we would like tointeract. Second, no one has promised us a successful outcome of our endeavours,even if we manage to interest others and collectively produce a new response tothe problems with which we are dealing. But perhaps the biggest cognitive and practical challenge relates to the fact that even when disappointments occur, asthey inevitably do, due to the non-cooperativeness of those with whom we wouldlike to co-operate, or to the non-effectiveness of the interventions we havestruggled for, the grounds for making classical criticism are still gone; having nomeans of scapegoating all there is to do is to start a constructive effort over again.

In my own estimation, this way of thinking about the concretizations, both asfailures and successes, of one’s hopes, ideas, and aspirations, is far away frommany contemporary intellectual engagements continuing to struggle for “episte-mological supremacy” rather than “ontological symmetry”. Whether successful ornot, this idea is a guiding inspiration for subsequent chapters. First, however, chaptertwo draws some (anti-)methodological implications for engaging ontologies fordeveloping things.

NOTES1 Classic actor-network analyses explored how and why networks of actors become stable (e.g. Latour,

1987). If patterns of actions are stabilized to an extent where the actors take them for granted, they




17

are said to be black-boxed . Black-boxed relations are naturalized and therefore difficult to investigateand change, not least because it has become hard to see that there is even something to change.

2 It can be argued, for instance, that unification indicates merely that the discipline is in a stable stateof “normal science,” as in (Kuhn, 1970).

3 The sociological focus on the content of science was initiated, not least, by the Edinburgh sociologistsDavid Bloor and Barry Barnes, and had two targets. Against classical sociology of knowledge, asrepresented by Mannheim or Merton, SSK aimed to show that the content of scientific knowledgewas, indeed, amenable to sociological analysis, and that the classical distinction between external

factors (which sociologists couldstudy) and internal factors (which they could not) did not hold.Against classical epistemology, they aimed to show that what was regularly characterized as internalto science was in fact influenced by the putatively external, and that the classical distinction betweenthe context of discovery (which might be messy) and the context of justification (in which the messwas removed and the logical core of discovery was elucidated) could not be upheld.

4

This makes events literally “just happen,” when understood in a real-time, rather than retrospectively(Pickering, 1995). It also introduces another vantage point from which to pinpoint the difference between nonhumanist and epistemological understandings of science, as Stengers indicates: “If wetake seriously the description of stories belonging as much to the history of the science as tocontemporary practices, and particularly the controversies aroused by any new proposition, we areobliged to conclude that the criteria of scientificity or objectivity that should allow thesecontroversies to be settled did not preexist them, but are on the contrary a major issue in discussions

between scientists. And this situation has not been changed at all by philosophers of science and thecriteria that they propose,” (Stengers, 1997: 81).

5 A very similar move is made in Latour (1986) that distinguishes between power understood astransmission of a substance (the diffusion model) and power understood as an effect of the successfulwork to stabilize associations among a set of actors (the translation model).

6 For example, Foucault temporarily participated in organizations such as Mouvement pour la Liberté

de l’Avortement (Movement for Freedom of Abortion) and the Groupe d’Information sur les Prisons,which worked for reforms of the penal system (Foucault, 2001: 418–23).

7 In a related move Isabelle Stengers has discussed issues of power in science. She contrasts minorityand majority science: “I mean by minority not a part of the population which is not, but could andtries to become, the majority, but active minorities who do not dream of obtaining for themselves the

power of a majority. Like Félix Guattari, I dream about multiple connections among minorities, sothat each of them would become able to work out its own singularity through the creation ofalliances, not in isolation, and so that each individual would be simultaneously part of manyminorities. Science, as I love it, is also a minority movement in a way (Stengers, 1994: 41). Whereasminority science is seen by her as “in league with power: the invention of the power to confer on

things the power of conferring on the experimenter the power of speaking in their name ” (Stengers,1997: 165) emphasis in original), majority science merely mimes this inventive capacity “with thesystematic production of beings constrained to “obey” the apparatus that will allow them to bequantified (such as the all-too-famous rats and pigeons of the experimental psychology laboratories).“In the name of science,” innumerable animals have been vivisected, decerebrated, and tortured inorder to produce “objective” data.” (Stengers, 2000: 22–23).

8 This links up with Isabelle Stengers suggestion that there is an inherent link between science anddemocracy, “In fact, as soon as one puts aside the classical division of responsibilities, which gives thesciences and their experts the task of “informing” politics, of telling it “what it is” and deciding what it“must be,” one comes face to face with the inseparability of principle between the “democratic” qualityof the process of political decision and the “rational” quality of the expert controversy . . .This double

quality depends on the way in which the production of expertise will be provoked on the part of allthose, scientific or not, who are or could be interested in a decision” (Stengers, 2000: 160).9 The Northwest passage refers to the much sought for polar passage, which would connect the

Atlantic Ocean with the Pacific. Michel Serres uses the term as an analogy for the construction ofconnections between seemingly non-related cultural and scientific ideas and events.



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10 The point is emphasized to provocative effect by Latour (1987) but has a long history. LouisMenand describes the following as a key tenet of classical American pragmatism: “In the end, you

will do what you believe is “right,” but “rightness” will be, in effect, the compliment you give to theoutcome of your deliberations. Though it is always in view while you are thinking, “what is right” issomething that appears in its complete form at the end, not the beginning, of your deliberation,”(Menand, 2001: 352).

11 This is precisely the problem analysed in Latour (1988).12 The term is from Gayatri Chakravorty Spivak, who defines it in the following way, “A strategic use

of positivist essentialism in a scrupulously visible political interest,” (Landry and Maclean, 1996:214).

13 Strategic essentialism is thus obviously a “majority concept” in Stengers’s sense: “Furthermore, I donot know which kind of power would define what it is to be anti-racist, anti-classist, anti-sexist, andanti-culturally-coercive. All I know is that if it is in a position to select and direct it will be a

majority power, and thus it will demand submission and refuse putting at risk the majorityformulation of their values.” (Stengers, 1994: 45).14 Isabelle Stengers suggests that: “In most cases, scientists and epistemologists have been in a great

hurry to explain this history, to show that the access was deserved and legitimate, the consequenceof an ultimate rational method or interrogation. They have made the method, which ensued from theevent, responsible for it, and have, as a result, obscured what is essential: no one has promised us

anything , and in particular, no one has promised us that, in all the fields of knowledge, the same typeof event will be reproduced,” (Stengers, 1997: 88).



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CHAPTER 2

RESEARCHING PARTIALLY EXISTING OBJECTS


INTRODUCTION

The previous chapter introduced some key concepts and areas of concern foramodern, nonhumanist analysis. Following on, this chapter asks the question ofwhat methodology looks like with an amodern disposition. To be precise, it is abouthow to study developing technologies, things not yet stable, or black boxed. As inseveral subsequent chapters the illustrative case has to do with the specific kind ofhealth care technologies called electronic patient records (EPRs). In the Danishcontext as abroad, EPRs have been imagined as crucial future components of theDanish health care system for at least fifteen years, and they continue to hold theattention of many different groups of people, such as nurses, physicians, engineers,medical informaticians, and politicians, as well as numerous STS researchers

(e.g. Jensen (2006), Jensen & Winthereik (2002), Olesen & Markussen (2003),Svenningsen (2003), Winthereik and Vikkelsø (2005)). Such actors have had partially overlapping yet markedly different reasons for engaging in EPR develop-ment and analysis and they have brought with them variable expectations, forexample with respect to how the EPR might change and improve working processesin hospitals.

This variability of interpretation and multiplicity of activities among the involvedactors is the starting point for the following analysis. Multiple actors have tried toshape electronic patient records, but for different reasons, with different means andto significantly different effect. Thus as my research began the electronic patient

record was precisely not yet a firmly stabilized actor in health care practices.Instead it was a developing technology, or perhaps several ones.

Multiple actors participated in attempts to make (various) kinds of new healthcare futures by means of new technologies. Meanwhile these technologies werethemselves under continuous transformation in order to respond to the variedexpectations made on their behalf. And, slowly and contingently, they started tochange health care practices and actors in return.

This chapter as well as several following ones (chapters 3–6) is based on a three-year study of the development of EPRs and their implementation in the Danishhealth care system. My initial research questions were quite general: ‘What are

these technologies?’ ‘Where do they come from?’ ‘Why do they come?’ and ‘Howare they developing?’ In a truncated explanation, I studied visions for the EPR, thedevelopment of these technologies, and their implementation. It would be fair tocharacterize these guiding questions as relatively diffuse. They were also rather



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naïve in the sense that when I started research much had been said about each ofthem. Yet, I would like to argue that such deliberate simple-mindedness in fact

turns into an analytical strength when the object of study is a not-yet-quite-existingtechnology; a thing whose existence is still only partial. The reason is that such peculiar objects of study require a kind of theoretical and methodologicalflexibility and attentiveness, which is all too easily diminished if one is certainabout how to approach the object because one already knows what it is and does.

I explored the development of electronic patient records primarily in relation toa large and ambitious project in the Aarhus region. The qualification ‘primarily’seems innocuous enough, but in fact it is crucial for the following considerations.The reason is that it turned out in practice to be impossible to stay within thegeographical, organizational and political parameters of the Aarhus Region, if onewanted to understand its development project.

Even though I started with the ambition of simply investigating the project inthe Aarhus region, I was quickly led elsewhere: for instance, to the Europeanstandardization organization and to sites of political contestation, regionally andnationally. The EPR, presumably made in Aarhus, seemed to be both there andelsewhere. It quickly became necessary to put the idea of studying the EPR in a singlecontext under scrutiny, since the technology seemed neither singular not singularlyattached to any one site. Rather, it seemed to be distributed, and located in whatI came to think of as a fractal landscape (see chapter six). In this landscape, thecontours of the EPR was (and is) subject to ongoing negotiation and revision as itgot (and gets) into contact with differently located and interested actors. The chapteranalyzes this uncertain ontological status and considers its methodologicalramifications by characterizing the EPR as a partially existing object (followingLatour (1999)). Several insights gained from viewing the EPR as a partiallyexisting object are not specific to this particular case but, rather, would be replicablein many other projects where ontologies for developing things are graduallyarticulated.

STUDYING WHAT?

As noted I studied the visions, development, and implementation of the DanishEPR. What then did I study, exactly? In fact, I continued for a long time to behaunted by my inability to specify and explain my research. Probably such unclarityof purpose is a rather well known phenomenon in early phases of research, yet itstill indicates a peculiar and awkward problem: how could it possibly be soconfounding to specify a set of coherent problems around EPR development?

Especially in academic terms there is something evidently troubling about this,since clear problem definitions and questions are usually viewed as a sine qua non

for conducting proper research. After all, if you don’t know what you are studying,

or precisely why, you can hardly investigate it. (Consider what you would usuallytell first year students on this issue…). There were thus obvious reasons forcontemplating this problem. Yet, I do not return to the issue because of a parti-cular interest in reflexivity. Instead of turning the problem “inwards” towards a



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With this in mind, the next part of the chapter will aim to clarify why it is sohard to state succinctly what one is studying when one is studying developing

technologies such as the EPR, and what one is, actually, studying. This will makeavailable for exploration a number of possibilities, which come into view whenone redefines the EPR, as I will continue to do, from a technological object, toa partially existing object operating in more or less fluid practices, in a more or lesscoordinated set of and networks.

WHAT IS AN EPR? THE PARADOXICAL ONTOLOGY OFA DEVELOPING ARTEFACT

Let me ask first what is an EPR commonly taken to be? It is easy enough to find

suggestions. For instance, the Danish National Board of Health, in their NationalStrategy for IT in the Health Care Sector 2000–2, offers the following:

An EPR is a clinical information system, which directly supports process-oriented examination, treatment, and care of the individual patient… “Process-oriented” means a patient record, which directly supports coherence andquality in the clinical treatment (15)

In this definition the EPR is centrally about supporting existing clinical practices, but offering a coherent technological framework for doing so. In other documentsthis challenge is specified as conceptual and terminological clarification and standar-

disation is just what the National Board of Health have aimed to provide. However,the National Board of Health holds no monopoly on determining what EPRs are.Thus it is also easy to find alternative definitions. The EPR development projectin the Aarhus Region of Denmark, for instance, adopted the definition from the National Board of Health, but stressed that several additional operational require-ments were important. For example, the EPR should be integrated with otherhospital information systems and the record should be available as an efficientwork tool for all kinds of health care workers. The Aarhus development grouptherefore emphasized that: “we are talking about long-term development projects,with an emphasis on organizational change and learning.”1

Now the fact that it is not difficult, but rather too easy to find competingdefinitions also indicates a potential problem. The problem is that as incompatibledefinitions appear to multiply it becomes correspondingly difficult to sort andevaluate which ones are better and which worse, which ones are more correct andwhich ones more faulty. This, of course, is a problem insofar as one is interested infinding out what the EPR really is and does.

For example: even though the description of what the EPR is about provided bythe Aarhus development group begang with a citation from the National Board ofHealth, it drew quite different conclusions about how this technology ought to become part of Danish health care practice. For, what mattered to the group in

Aarhus, was not primarily conceptual standardisation but organizational change.The group, however, had no principled opinion about whether the terminologicalstandardization promoted by the Board of Health was the only or best solution toachieve this goal.




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Further, the report from the Aarhus group was no more authoritative than theone from the National Board of Health; not even within the frame of the Aarhus

project. For example, nurses, secretaries and doctors provided quite different view- points on this matter when they were placed in working groups in 2001, in order toformulate responses to questions such as “How they would work on 01/04–04?How it would be possible to plan a good implementation process to make allgroups of personnel feel safe about the new system? How to de-mystify the EPR?and How to prepare the personnel in IT-terms?” (Secretaries’ report: 3–4, Nurses’report: 4).

The secretaries focused primarily on the need for education and interdisciplinaryinteraction, since they saw these dimensions as crucial for the successful organi-zational transformation, which they expected would be brought about by the newtechnologies. They also reserved critical commentaries for the monodisciplinary set-up of the working groups, because it prevented what they viewed as necessaryinterchanges between the different groups about these organizational consequences.

The nurses’ group concurred and said that: “the lack of contact between thegroups has necessitated an array of assumptions concerning the routines and workflows of other professional groups” (5). Even as they said so, however, they excludedsecretaries from their concerns, and concentrated on the hoped-for changing relation-ships between doctor and nurses. This led them to suggest that workflow analysesshould be carried out at each ward, so that the EPR could be used to create beneficial changes in working arrangements. They also discussed the implicationsof various arrangements of hardware, such as “EPR work spaces are located in anoffice adjacent to the ward”, “a portable computer is placed on a moving table,transported to the patient”, or “doctors and nurses each have a pocket PC” (7) withthis issue in mind.

Meanwhile the main concern of doctors was precisely whether they would be protected against unwanted new tasks (which to a significant extent overlappedwith what the nurses considered beneficial changes in working arrangements):“Will the implementation of the EPR entail task slippage, so that the group ofdoctors will be expected to take care of more routine tasks, such as writing in the

record, booking of examinations etc ‘ since it is so easy’?” (Doctors’ report: 4,original emphasis). To avoid considering this unpleasant possibility they decidedto view the EPR “with visionary doctors’ eyes” (3) and proposed that: “it is importantthat specific groups retain the possibility of emphasising/justifying the specificinterests and problems in relation to their own tasks” (5). In their analysis it wasassumed that “everything concerning security and backup is, of course, solved, suchthat the system is up 99,9% of the time, and the remaining 0,1% is taken care of ”.And the report offered suggestions such as that “the table top of the moving table forthe ward round, by the way, is a computer with finger touch screen”, capable ofshowing x-rays and “when you have dictated a note to the EPR (secretary or ‘voice

recognition’) it immediately appears as a draft on the screen” (9).In this short presentation of the analyses of secretaries, doctors and nurses, wesee the articulation of different versions of the EPR. For nurses and secretaries theexistence of the EPR was associated with changing working relations although in



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different ways. Doctors, meanwhile, decided to view the EPR as a neutral techno-logical tool, which might stabilize and render more efficient current organizational

and disciplinary divisions of labour. We can also note how the EPR moves froma purely terminological-conceptual entity at the National Board of Health to anorganizational technology in the Aarhus project, which once again splits into manyversions in the hands of different health professionals.

Because understandings of what kind of entity the EPR is and what kind ofimplications it has are proliferating and variable, the researcher may feel an almostirresistible urge to decide whose definition to believe in, whose agenda to prefer. Ifone expects the object of inquiry to be static and homogenous this is even required,since the research task will then precisely have to do with figuring out who is rightin their descriptions of the technologies and their estimations of implications, forexample for organizational arrangements. But although this is a venerable approachin social science, there is another option; one can follow Michel Foucault and benominalist.

What is a nominalist? According to literary theorist Barbara Herrnstein Smith,a nominalist answers the question “What is X?”, for example: what is truth?, whatis knowledge?, what is value?, or, in this more mundane case, what is an electronic

patient record?, by insisting that X is, in the first instance, a word, with a history ofvariable and still changing usage. Such insistence certainly adds interpretiveflexibility to an investigation. It leads one to expect variable answers to anynumber of questions regarding the object: What is the EPR? Does it even exist?What does it do? Where is it found? What are its benefits, risks and costs? And forwhom? According to nominalism all the different answers given to such questionmust be taken as reasonable contextual responses to the given question. In contrast,if one starts out assuming that the EPR is a specific bounded something (which asa researcher one has special mental capacities for recognizing or methodologicaltools for unravelling) then alternative suggestions encountered in practice mightwell be viewed as deviant, benighted and, perhaps, to be corrected. (“If only theyreally knew what the technology can do for them, then they would not resistimplementation”). This preliminary observation can be read as a re-statement of the

anthropological commonplace that the interpretations of all involved actors should be treated equally, or symmetrically, to ensure that “official” or “institutionallysanctioned” perspectives are not simply replicated in analysis.

Yet one thing is obvious so far: the analysis offered seems quite distinctly“discursive” or “social constructivist”. In fact, we have so far not encounteredthe “thing itself ”, the electronic patient record that, qua nonhuman thing, I have begun to intimate plays such a central role in generating future networks of healthcare practices. To grasp how technological actors such as the EPR do enter theanalysis it is crucial to understand that although nominalism is the analyticalstarting point of amodern analyses, enumeration of perspectives need not be the

end-point of investigation. This is where insights from actor-network theory andrelated nonhumanist approaches become pertinent, due to their emphasis thatobjects should not be understood simply as the passive receptacles or stable centresto which human actors’ interpretational work attach and relate.




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Instead, Annemarie Mol proposes, one ought to look closer at the practices inwhich objects are manipulated:

If practices are foregrounded there is no longer a single passive object in themiddle, waiting to be seen from the point of view of seemingly endless seriesof perspectives. Instead, objects come into being – and disappear – with the practices in which they are manipulated. And since the object of manipulationtends to differ from one practice to another, reality multiplies…Attending tothe multiplicity of reality opens up the possibility of studying this remarkableachievement (Mol, 2002: 5)

Mol calls this approach empirical philosophy. It is philosophical in its interest inunderstanding knowledge and knowledge production. But it insists that this can

best be grasped through detailed studies of how people and things becomeassociated in practice. And this connects Mol’s philosophy with the study of partially existing objects:

A new set of questions emerges. The objects handled in practice are not thesame from one site to another: so how does the coordination between suchobjects proceed? And how do different objects that go under a single nameavoid clashes and explosive confrontations? And might it be that even if thereare tensions between them, various versions of an object sometimes dependon one another? (Mol, 2002: 5–6)

I previously wrote that the EPR, in the first instance, has to be viewed as a word.How is this connected with Mol’s argument that urges us to attend to materiality, practices and objects? It is crucial to understand that this is not a “performativecontradiction”. Instead, the point is that such shifting frames of reference arenecessitated by the ongoing transformation and variable ontologies of the techno-logies we study. And the EPR precisely illustrates this point.

Traced in practice, “it” traverses modern dichotomies such as object/subject andmateriality/discourse. As one encounters “it” empirically, the EPR is sometimesa word, a text, a vision, a procedure, a prototype, an interface and a database. Onecannot decide in advance whether the referent is linguistic and rhetorical to be used

for political bargaining, or a piece of software used by nurses for medication purposes, or quite possibly both at once as well as other things.

Prior to empirical scrutiny, one simply cannot be sure whether the EPR issomething “envisioned” or something “concrete”. In some places the EPR seems toexist, but others will argue that what one can encounter at current hospitals is atmost vaguely related pre-cursors to the real thing. In some places “it” is being built, but as it exists only in beta-versions, and remains untested in practical situations pronouncements on its reality are marred by uncertainties.

Furthermore, the EPR is variably understood in local terms: developed asa solution to very specific medication procedures and problems, or in national

terms: as an initiative carried out by the National Board of Health to rescue theDanish Health Sector from a babel of varied practices and uncoordinated efforts,compromising patient safety as well as health care economy. One simply cannotknow once and for all whether the EPR is discursive or material, local or



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national, a good idea or a large problem, technical or political, or if it is all ofthese things to varying degrees at various times and in various places. If it is

presumed that entities have fixed and stable properties this is a paradoxicalclaim, but the paradox diminishes if one begins to think in terms of variable practical ontologies; that is, if one starts imagining that the properties of objectsare precisely not essential, but that existence builds and transforms gradually, as properties are loaded into and conferred upon technological things throughrelations with new practices.

If one studies technological projects and development – ontology for deve-loping things – one has to be “nominalist, no doubt” as Michel Foucault (1990: 93)expressed it. Methodically, this entails that one takes serious the assumptionthat any entity is a word “in the first instance”. In the first instance but notnecessarily in the last instance, since the point of following the processeswhereby objects garner partial existence is precisely to learn how it is possiblefor actors to undergo ontological phase-shifting, from being mere words to becoming properly technical objects with well-known and reliable capacities andfunctions.

There is thus a double suspension at play here. For just as empirical philosophyhas no investment in pre-determining what an actor must be it (in the first instance itis simply a word) does not need to insist that, in the end, all is discourse (in thelast instance it may have become a technical object). And, of course, words andvisions sometimes, if not always, do materialise as technological reality,although they invariable transform in this process. The argument is thus that byletting go of both a priori conceptions of what technologies really are anddeterministic understandings of what they must turn into, facilitates the study of partially existing objects – as the study of practical ontology for developingthings.

WHERE IS THE EPR? LOCATING PARTIALLY EXISTING OBJECTS

Since the mid-nineties anthropologists and sociologists have discussed the methodo-

logical problems that emerge when social research turns to empirical study ofinformation technologies (e.g. Newman, 1998; Star, 1995). The well-known ideathat the researcher steps into a clearly defined field site runs into constant troublein relation to the study of IT in which the object almost per definition is distributed(see e.g. Cooper et al , 1995). But while this has posed challenges for the classicalethnographic ambition of surveying one’s entire field, it has also enabled theemergence of a new set of opportunities and insights. Not least, it has facilitatednew analyses of how the supposedly very large, or even “global”, is interrelatedwith the supposedly very small and “local”. What connects the insignificant micro-actor and the powerful macro-actor? Materiality does. Research into the ontological

processes through which technologies gain and lose existence produces knowledgeabout such relations. In potentia the EPR associates multiple sites that were previously unconnected, thus producing a change in scale, from the micro towardsthe meso or even macro.




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If one explores a technology that appears sometimes to be local, sometimesglobal, it will thus be with an interest in understanding how the object becomes

linked with other actors in ways, which make them mutually stronger, add to theirexistence and therefore make them more global in reach (or vice versa). Thenational or global technology in this view is simply the one that has been mostthoroughly and intensively socialized, has gained most in reality, and therefore has become most capable in tying together and fitting into multiple disparate practices.

As we will see in more detail in the following chapters, these processes arevividly illustrated in the case of the EPR. Here, multiple actors from multiple sites,such as the Danish government, the regions, the National Board of Health, thehealth professional and patient organizations, individual hospitals, the medicalinformatics community, the Board of Technology, as well as software companies,standardisation organizations, and medical jurists are all engaged in trying to defineand influence technological development and predict its consequences. And, ofcourse, these actors do not only speak and write, they participate in multiple otheractivities as well. At the time of my research this was most visible in the attempts bydifferent Danish regions to develop a well-functioning EPR model. To be able todemonstrate a successful system to politicians, other hospitals, and the public, was presumed to be a much stronger argument for the adoption of that particular system asthe national standard than any amount of analysis and argumentation.

All this adds up to an argument that it is, in fact, quite complicated to studytechnological development in distributed and politicized environments, although forsome other reasons than one might have imagined. What one investigates in suchinstances seems not to be a technology, which happens to be multiple and distributed.Rather, the EPR is a vivid, even dramatic illustration of the partial existence charac-terizing technologies under development; ontologies that vary and emerge in practiceas multiple material and discursive resources are woven together or fall apart.

This makes explicit the possibility that the EPR might exist in a diversity ofmodes. Or is it rather: it makes visible the fact that different varieties of EPRsexist? The first expression suggests that the EPR is really one technology thathappens to be realized differently in different contexts. The second proposes

that there is no single unambiguous EPR because the many different technologies posing under that name are not common enough to share existence. The questionabout ontological cohesiveness and commonality is not nearly as esoteric as itsounds because it has immediate consequences for involved actors. For example itmattered deeply for the relation between the Danish Board of Health and thevarious regions, since regions were threatened with sanctions should they fail todemonstrate that their EPR models were similar enough to the one promoted by the board. But it holds central significance for the researcher interested in ‘practicalontology’ as well. For the activities engaged in by diverse actors in order todemonstrate similarity provides additional knowledge about the generation and

transformation of technological futures; their ontology and relations. It facilitatesthe asking of questions such as: How are technologies, procedures and practices built in order to facilitate comparison? Indeed, how are these scales of comparison built, challenged and changed, and by whom? If actors engage in an ongoing



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reshaping of existence – both of the EPR and themselves – through such work, thendocumenting and analyzing such processes are crucial for understanding how

health care futures are generated.To sum up it is in principle impossible to know whether we are dealing with

one or several EPRs. In practice, however, it can be established by empiricallyfollowing the ontological work, which actors put into adding existence to one oranother version of the EPR; a work which gradually transforms organizationalstructures and health care professional relations, as well as technological infra-structures. This situation also makes clear why the distributed and partial existenceof the EPR has been both an asset and a liability for the many actors who have been involved in its development. The strength has been that it has ensured a very broad support of such development, since almost everyone has agreed that theEPRs would be beneficial for the health care system. Yet, the weakness has beenthat the EPR has remained difficult to control, classify and specify, precisely because the multifarious interests with which the technology has been invested, hascontinuously threatened to fragment the object; turning it from one to many.

ONTOLOGIES FOR DEVELOPING THINGS

In this chapter I have developed some (anti-)methodological implications of amodernapproaches to the study of technological change. I have focused especially on the

variable and changing ontologies of technical objects, and pointed to the diverseforms of heterogeneity and variability of the object usually called the EPR. By nowthe reader will be excused if he or she thinks the point is to show that the EPR isa quite fickle empirical object; one which it is rather hard to freeze analytically.This, of course, it is, in a sense, and it is important to recognize as much. Yet, the point has not been to argue for the complete randomness of the technology or thedevelopment process. Rather the argument – to be substantiated in the followingchapters – is that it pays off to make an effort to distance oneself from the mostcommon clichés about technological development. One particular merit of amodernapproaches is that they offer a mode of analysis that can handle that technologies

do not behave as stand-alone, homogenous, static objects. This makes it possible toclosely follow the multiple associations created between things, humans, discoursesand organizations, as numerous actors attempt to shape new and as yet only weaktechnologies and associate them with their specific practices, adding to their partialexistence in particular ways.

As I aim to show in the following chapters, bringing an amodern disposition tothe question of technological change, makes it possible to ask questions about whythe existence gained by the EPR sometimes seems to be paid for by other human ortechnological actors, whose existence it threatens, whereas other versions of theEPR seem able to co-exist with many other actors, and yet others appear able to

lead indifferent and parallel infrastructural lives. And it enables the study ofontology for developing things; that is, the exploration of why and how a thing becomes a coherent object, or, alternatively, why and how a thing is turned intomultiple, fragmented, things, or, sometimes, is turned into nothing at all. These are




questions that the next chapter continues to explore, as it focuses on how theelectronic patient record emerged, gradually gained existence, and began to

generate new futures in the Danish health care context.

NOTES

1 Visited at: http://epj.aaa.dk, 15/4-2002 (no longer accessible).

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