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Wen-yuan Linbeyond Haemodialysis Practices

Displacement of Agency : The Enactment of Patients' Agency in and

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Article

Displacement ofAgency: TheEnactment ofPatients Agency in

and beyondHaemodialysisPractices

Wen-yuan Lin1

Abstract

How might the agency of the subaltern be conceptualized within the

intersection of multiple worlds? Actor-network theorys (ANT) translationframework for understanding agency portraying this as entrepreneur andtalking of a world in the making is arguably imperialist, managerial, and

monolithic. Draws from the enactment turn of ANT and insights into thepolitics of representation, this article elaborates an alternative frameworkwhich focuses on displacement. By examining the case of dialysis patients,the article explores the displacing practices that follow the disruption of

routines in dialysis. Patients have to go through a process of problematiza-tion, distribution, hybridization, and restabilization, in order to sustainthe coexistence of their alternative practices with dialysis. Unlike

1 National Tsing-hua University, Hsin-chu, Taiwan, Republic of China

Corresponding Author:

Wen-yuan Lin, National Tsing-hua University, No. 101, Sec.2, Kuang-fu Rd. Hsin-chu, 30013,

Taiwan, Republic of China.

Email: [email protected]

Science, Technology, & Human Values

38(3) 421-443 The Author(s) 2012

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entrepreneurs in the translation model who transform the world by inter-esting others, enduring trials, and becoming spokespersons for all, thosepatients who manage to displace and sustain the coexistence of multipleworlds avoid interesting, still less confronting, the hegemonic actors and

claiming representation for themselves. This article suggests the displace-ment of agency as a generic alternative.

Keywords

actor-network theory, agency, representation, patient, subaltern

Introduction

How might the agency of the subaltern be conceptualized within the inter-

section of multiple worlds? Actor network theorys (ANT) translation

framework treats agency as the effect of a series of processes which include

problematizing, interessment, enrollment, mobilization, and representation

(becoming a spokes-person; Callon 1986). More recently, ANT has becomemore aware of the complexity and multiplicity of practice (Law and Has-

sard 1999; Gad and Jensen 2010). Nevertheless, in its original version it was

accused of being imperialist, managerial, monolithic, and unduly

dependent on models of entrepreneurial agency (Star 1991; Fujimura

1992; Lee and Brown 1994). As a part of this, it was argued that the experi-

ences of marginalized actors struggling in and between already-made net-

works do not fit the standard ANT scenarios, and their agency does not

find a place in the trope of the trial (Mort 2002; Star 1991; Singleton andMichael 1993).

This article draws from the enactment turn of ANT and insights into the

politics of representation, to develop an alternative conceptualization of

agency. It explores the ways in which dialysis patients in a particular con-

text in Taiwan manage the intersections between practices of biomedical

and alternative medicine. It does this by considering what happens when

dialysis routines are disrupted. Initially, such disruption renders the agency

of patients indeterminate. Subsequently, patients go through a process of

problematization, distribution, hybridization, and restabilization as they

restore their agency by mixing alternative therapies with dialysis practices.

But this process reveals that patients work by displacing their problems

rather than translatingthem. In particular, it reveals that this process of dis-

placement makes it possible to combine dialysis with alternative therapies.

422 Science, Technology, & Human Values 38(3)

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The article thus proposes that displacementshould be understood as an

alternative to translation. In the translation model, action takes many

forms, but most attention has been paid to agonistic agency. The exemp-

lary case comes from science in action: when a scientific object success-

fully endures trials, a contested statement is black boxed into an

established fact/truth, and the scientific entrepreneur makes himself or

herself the spokesperson for the truth (Latour 1987). Despite challenges,

this original formulation of agency remains substantially intact in much

writing influenced by ANT (Akrich, Callon, Latour 2002a, 2002b; Latour

2005, 43-62). This displacement model challenges thisand the politics

of representation by drawing from Gayatri Spivaks (1988) concern withsubaltern representation. Spivak distinguishes between representation as

delegation (vertreten) and representation as re-presentation (darstellen)

in imperialist and nativist empirical accounts of Hindu widow immola-

tion. She argues that this conflation (a false understanding of the world

as representation-darstellen) effaces representation-vertreten and ren-

ders the oppressed as the inaccessible Other. However, as ANT reminds

us that representation is more than textual or discursive practice, and

reality is done in interconnected local materialsemiotic enactments byheterogeneous participants, including patients (Law 2004, chap. 2). The

ways in which patients devise tactics to prevent confrontation with med-

ical personnel suggests that displacement represents an important form of

subaltern agency.

Enacting Agency

The enactment approach adopted by actor network theory implies a prac-tical ontology; rather than treating reality as something that is con-

structed by substantial and pregiven actors, it treats this as an effect of

sustained enactments or performances (Lin 2007; Jensen 2010, 7). As

Annemarie Mol notes, ontologies are brought into being, sustained, or

allowed to wither away in common, day to day, sociomaterial practices

(2002, 6). Extending this approach to biomedicine brings out a new

understanding of medical settings: the development of heterogeneous

things in the making of biomedical reality (Jensen 2010). The enactment

approach opens up a world in which diseases, patients, protocols, medical

personnel, medical records, examination, techniques, instruments, treat-

ments, laboratories, and organizations all play their part in the making

of the sociomedical world (Berg and Mol 1997, 1998; Prout 1996; Van

der Pleog 1995; Law and Singleton 2003; Jensen 2005).

Lin 423



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As a part of this, enactment approaches make no assumptions about the

character of agency but seek instead to explore how this is constituted in

multiple sites of practice (Law 2004). Studies of how wheelchair users put

themselves in different settings in making spatial passages and of how peo-

ple suffering from spinal muscular atrophy and diabetes using orthodox

medicine and alternative therapy and measuring blood sugar and feeling

the body, show that they are able to configure and maintain different modes

of agency (Mol and Law 2004; Moser and Law 1999; Callon and Rabehar-

isoa 2004).

This tells us that while managing their bodies, selves, and diseases,

patients participate in the enactment of particular ways of being in whichtheir agency unfolds. Mols (2002) ethnography shows that there is not one,

but rather multiple versions of atherosclerosis. The disease is variously

enacted in different and situated practices in daily life, the clinic, the pathol-

ogy laboratory, and the operating theater. Cussins (1996) explores the

dynamic unfolding of agency in in vitro fertilization practices. While

women are still in active treatment, medical procedures are seen to fit with

agency. If treatment fails, the women talk of feeling alienated or dehuma-

nized. These inconsistent accounts suggest that the subject participates andthat understanding of ones own agency rests in the unfolding of the uncer-

tain trajectorieswhat Thompson calls an ontological choreography of

womens agency.

The final move is to realize the enactment potential for understanding the

contingent unfolding of agency in the intersection of multiple worlds. The

body multiple and ontological choreography are made within and

between the contesting enactments of an established world, resting in the

hospital and in forms of treatment that are mainly organized in terms of abiomedical regime. What happens to their agency when patients attempt

to act in ways that are radically different, such as traditional Chinese med-

icine and spiritual therapies?

Tackling how Chinese medicine or forms of spiritual therapies interfere

with biomedicine might seem a large topic for a single paper. The strategies

of translation, mapping, temporalizing, and repositioning of traditional Chi-

nese medicine in the encounter with hegemonic biomedicine in the contem-

porary China and worldwide have been widely discussed (Lei 1999; Barnes

2003; Scheid 2002; Kim 2007; Zhan 2009). Yet the specificity of patients

involvement and the constitution of their agency in the intersection is

exactly the focus of this article. The argument is empirical, and this is

because large systems only ever relate together in specific empirical prac-

tices including those in which patients manage their medical condition.




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Accordingly, I focus on a serious specificity: what happens after the failure

to insert the needle into the fistula1 in hemodialysis, without which patients

can no longer use dialysis to sustain their lives. The cases are taken from

fieldwork notes and interviews from a period of participatory observation

in a dialysis clinic in Taiwan, a country where alternative medicine is pop-

ular. Names and places are anonymized.

Problematization

Patients with end stage renal failure disease (ESRD) rely on regular dialysis,

a standard therapy in biomedicine, to sustain their lives. This is normally

done three times a week. A fistula is literally a patients lifeline, because

a well-functioning fistula is essential for the successful insertion of a needle

to drain out sufficient blood for dialysis. The whole biomedical deployment

of a dialysis clinic relies on this lifeline to connect patients and enacts

patients as capable of dialysis. Therefore the failure to insert a needle is a

short but nonetheless critical moment for a patient.

Mr. Lee lies on the bed looking at his left forearm. A nurse, Ms. Chiu, is hold-ing a needle in her right hand and using the index finger of her left hand to feel

around Mr. Lees fistula. Another nurse, Ms. Hsu, is helping Ms. Chiu; her

right hand is pressing a cotton ball onto the other end of Mr. Lees fistula.

Occasionally she interrupts Ms. Chiu by touching Mr. Lees fistula and mak-

ing suggestions about where it might be better to insert the needle. Mr. Lee

and the nurses look worried.

This is the second attempt. In the first, the needle went in but no blood

came out. After a few adjustments, blood appeared but Ms. Chiu thought thatthe flow was not strong enough. Therefore, the needle was pulled out. After

asking Ms. Hsu come to help, they were preparing for another try.

How was the agency of the patient transformed in these fistula-related prac-

tices? Patients do not normally worry about their ability to acttheir

agencyto sustain their dialysis. Dialysis is a standardized therapy for

medical personnel and a routine treatment for patients. Extending Laws

(2004, 131-34) insight, the possibility and ability of a patient to do dialysis

is an effect enacted in dialysis method assemblages composed of knowl-

edge, machines, medical professionals, medical records, a fistula, and

blood, and so on.

If everything had proceeded according to plan, the well-stabilized rou-

tine and the agency deployed as a part of this would not have changed, and

Lin 425



8/25

the issue of the agency of the patient would not have been raised.

However, the first attempt to insert the needle had failed. The flow of

practices mediating Mr. Lees agency to do dialysis was stopped, and the

assemblage of his agency were no longer taken for granted. The failure to

insert might mean nothing or it might be a disaster; at best it was due to

the poor technique of Ms. Chiu, while at worse it meant the fistula had

shrunk and Mr. Lee would need to have a painful dilatation operation

to expand the fistula or even worse to have another fistula rebuilt. This

makes it one of the moments when patients are scared; sometimes

described by patients as the end of the world for it could be that they

cannot do dialysis anymore.Despite the potential for severe consequences, at this moment Mr. Lee

could do nothing but wait. Ms. Chiu was searching for a better part of the

fistula for another attempt to reenact the dialysis deployment. If it worked,

then it might have nothing to do with the fistula. But until then the prob-

lem would remain undecided and the configuration of Mr. Lees agency in

dialysis would remain indeterminate.

Distribution: Displace the Problem out of the Clinic

But indeterminacy is usually resolved. Let us return to the scene.

The second try succeeds. When things are settled Ms. Chiu disconnects the

tube and the syringe attached to the needle and puts on another tube and syr-

inge. The blood in the used syringe and tube is diluted by saline solution in

the syringe and turns light red, but there are some dark red tissues floating

in the solution. Ms. Chiu shows the syringe to Mr. Lee and says: Sorry about

that. But your fistula is really not good. There are clotting tissues in the blood

coming out of the fistula. See, here. Do you hot compress your fistula the day

after dialysis? Your fistula is so hard. . . .

Mr. Lee does not say anything but glances at the syringe. Ms. Hsu follows,

Yeah, it is so hard. You dont hot compress, do you? Mr. Lee twitches his

mouth and reluctantly says, I dont have the time. Then he keeps looking at

his fistula and occasionally touches it with his left hand.

Ms. Chiu then gives Mr. Lee a few sheets of paper which describe how to

exercise and hot compress, reminds him to ask the doctor to prescribe some

medication, and advises him to consult a surgeon if his fistula needs a dilation

operation.

Dialysis had to carry on and at the same time the question of agency was

moved forward and configured. To do so, Ms. Chiu and other actors had




9/25

to do a great deal. Ms. Chiu changed the syringe, apologized, and she also

showed the clotted tissues and told Mr. Lee what had caused the clotting.

By going through the causal relations of the problem, Ms. Chiu reenacted

the failed configuration of Mr. Lees agency. Here Ms. Chiu representedthe

problem; she distributed the failure to Mr. Lees daily self-care, rather than,

say, her skill. But Ms. Chius practices alone could not complete this distri-

bution unless other actors did their work: the clotted tissue and the hardened

fistula were turned into forms of demonstration, and even Mr. Lee

participated in the enactment and remembered what went wrong. But the

representation did more than this local enactment. John Law suggests that

representation is:

[T]he enactment of a bundle of ramifying relations that shapes, mediates and

separates representations in-here, represented realities out-there, and invisi-

ble out-there relations, process and contexts necessary to in-here. (2004, 84)

So what is happening to agency here? The configuration of Mr. Lees

agency seemed to be narrowed down to the fistula but was actually

expanded to Mr. Lees daily life. Mr. Lees inability to do dialysis was fusedwith the facts of seeing the clotting, feeling the hard fistula, remembering

that he had neglected his fistula, and reflecting on his lifestyle that was too

busy to allow him to hot compress. The breakdown of the routine configura-

tion of agency that achieves dialysis was distributed to the lack of other

forms of patient agency, such as performing daily care. Moreover, the bio-

mechanical mechanism of and solution to a clotting fistula were also

enacted in the animal experiments of laboratories, compared, discussed, and

validated in the clinical reports in journals, authorized in the narratives oftextbooks, and taught and practiced in the training of dialysis personnel.

They were done in a wide range of locations within biomedicine. Thus, this

episode distributed the problem to the fistula and Mr. Lees daily practices,

and configured Mr. Lees agency by resonating with the enactments of a

biomechanical body in biomedicine.

But there are different distributions and configurations. Mr. Chen and

Mrs. Lai had similar problems but they had a different plan. Mr. Chen told

me:

I believed in western medicine before as you do. At that time I took so many

medication prescribed by doctors but I was weak. Sometimes I came to dia-

lysis on a wheelchair. . . . Then a miracle happened. Since I followed the

Sacred Mother, I am getting better and better.

Lin 427



10/25

I asked what happened and who the Sacred Mother was. He replied:

Sacred Mother is embodied by the Avalokitesvara. In her temple, she offers

holy water that cures lots of people. While drinking the water, you have to

chant a religious script sincerely a couple of times . . . . She also uses a rod

to beat you on the back to reduce the sin handed down to you from previous

lives. Our bad temper, bad luck, and disease are caused by these sins. . . . She

also teaches us san ji shi (good knowledge), it is about how to follow the

heavenly gods principle of treating people well, serving your parents, and

doing good. Following good knowledge, we not only do not accumulate sin,

but also reduce those from previous lives, we save our sacred heart. . .

I asked him how this helps him. Mr. Chen says: Quite a lot. Last time myfistula was clotting, the medication was useless and I was told I needed a

surgery. . . . My uncle who was saved by the Sacred Mother in a car accident

took me there. On the first visit, I was reluctant and he forced me to try the

water. Magically, my fistula got better afterwards. Then I went again and

again by myself, and asked for more help sincerely. I also do my best to

do good, and spread good knowledge in daily life. See, I didnt have the sur-

gery, but my fistula got better . . . Now I go there regularly. . . . Thanks to the

Sacred Mother, I am much stronger and now I work in my uncles furniture

factory. Can you believe it? I can carry a shelf that is two meters high to thefifth floor on my feet!

Mrs. Lai was new to dialysis because of her diabetes. She usually needed to

have excess fluid removed in a dialysis session and ended up with low blood

pressure. After a few months, she often had failed insertions. According to

the nurses, a fistula clots easily when there is prolonged low blood pressure.

Apart from hot compressing, nurses also suggested that she should not drink

too much. But that did not work. Mrs. Lai was worried, at first she com-plained: I barely drink water but still retain lots of water in my body. Six

months later I interviewed her while she was having dialysis. Everything

was fine. She told me:

I visited a very good Chinese medical doctor recently. In the last few years,

I had visited so many different doctors, even some ridiculous alternative

therapists, but none could do anything about my diabetes, and I ended up

on dialysis. But this one is very good. . . . He is good at palpating. In the first

visit, simply by palpating, he told me that the problem was my phlegm-

dampness somatotype. The obstinate phlegm-dampness weakened the spleen

meridian that governed the circulation of blood, which furthered weakened

the lung meridian that governed the circulation of water. . . . He prescribed

herbs for one month and powdered medication afterwards, and wanted me eat




11/25

more almond and Chinese yam that were good for the circulation of chi

(vital energy flow) in the lung and spleen meridians. Since then I do not retain

so much water anymore.

When I asked her more specifically about the fistula, she said: I asked the

doctor do I need to have a dilation before the fistula shrank. He told me that

the surgery was a downstream solution, and my problem was first about the

phlegm-dampness. It weakened the spleen meridian that couldnt produce

good quality of blood and circulate it well. The situation got worse, and

my lung meridian was weakened and couldnt circulate water properly. So

I retained water. If we did not solve the upstream problem I would need to

have the operation again and again, for the blood was still sticky and my bodystill retained water.

Dialysis requires patients to follow biomedical practices in the clinic and

other parts of their lives. However, because of patients lifestyles, habits,

working conditions, family and religious backgrounds, and financial status,

and so on, patients try to solve their problems using biomedical and alter-

native medicine at the same time. Therefore, patients sometimes find other

way of arranging their agency.

To tackle a similar fistula problem, Mr. Chen and Mrs. Lai took part in

enactments of alternative causalities, solutions, and configurations. In the

case of Mr. Chen, the practices linked the fistula problem to the relation-

ships between the sacred heart, the accumulation and reduction of sin, and

the embodied consequence of being a sinner. They related the solution to

practicing good knowledge in daily life and therapies in the temple. And

they configured Mr. Chens agency in the enactments of a spiritual body in

a particular religious form of medicine. In the case of Mrs. Lai, what was

enacted distributed the problem to the relationships between the phlegm-dampness somatotype, the interaction between the meridians, and the circu-

lation ofchi and blood; the solution to taking herbal and powdered medicine

and eating chi-enhancing food; and the configuration of Mrs. Lais agency,

to the enactments of a chi body in traditional Chinese medicine.

Hybridization: Displace the Alternative Therapies

into a ClinicThe alternative configuration of patients agency is not simple. While

dialysis is practiced in a well-regulated clinic, alternative medicine is less

integrated. Patients have to find ways through the various sites for them-

selves in order to do alternative therapies. This implies that instead of

Lin 429



12/25

following the established dialysis deployment, patients have to go through,

and sometimes organize, contingent and hybridized trajectories. For exam-

ple, Mrs. Lais journey in Chinese medicine is more than shopping for a

doctor. She also mentioned that when she took herbal medicine for the first

time, she tried many Chinese medical pharmacies in order to buy better

herbs, learned what kind of stewpot is better for stewing the herbs, learned

how to stew, and coordinated her daily working life with the stewing and

dinking of herbal soup, and so on. In order to generate an alternative version

of agency, Mrs. Lai needs to go through a contingent trajectory, to hybridize

the practices of various sites, and build herself an alternative medical world.

More importantly, patients like Mr. Chen and Mrs. Lai were not onlyusing alternative medicine in a temple and a Chinese medical clinic but also

receiving dialysis; they sometimes brought these practices into the dialysis

clinic. Despite the fact that dialysis professionals were opposed to these

alternative therapies, there were rarely confrontations between the patients

and medical personnel, and only occasional disturbancesa function of

how well they collectively manage the contingencies. This is illustrated

in the following.

Mr. Lee gives Ms. Chiu a report from the surgeon he visited, says: the doctor

said my fistula was ok. No operation was needed now. Hot compressing

would do. Ms. Chiu receives the report and replies: but do you hot

compress? Mr. Lee nods. Sure, more than that I bought an infra-red heater

I used in the clinic. Before the examination they had me radiated for thirty

minute on the fistula. I felt that the blood flowed stronger. When leaving,

I saw an advertisement saying that it could be used for daily care. So I bought

one. Now, I either hot compress or radiate every day. . . .

Is it safe? Ms. Chiu asks. Mr. Lee replies: sure, its manual includeslicenses and reports. I will show you next time . . . . Then they discuss his

medication, Mr. Lee adds: Im taking fish oil recommended by a patient in

the waiting room of the surgery. Ms. Chiu does not trust in the fish oil. She

asks him to stop taking it until she has had a chance to check it out.

A few days later, Mr. Lee brings the manual and a bottle of fish oil cap-

sules. Ms. Chiu and doctors are satisfied for the fish oil is approved by some

EU authority and the irradiation instruments clinical trials are published in

prestigious nephrological journals, and it is approved for clinical use by

Taiwanese Ministry of Health. The doctors are quite interested in the

instrument.

Mr. Lee did much more than simply following Ms. Chius instruction.

He brought in the enactments from other sites; he was heating and hot




13/25

compressing his fistula and taking medication with functional food at

the same time. It was debatable whether these alternatives belong to the

dialysis networks, as both were approved by authorities allied to biome-

dicine; nevertheless it is clear that the new practices slightly changed

the configuration of Mr. Lees agency. The degree of change depended

on how well the foreign enactments were articulated. As a matter of

fact, after consulting their colleagues in Taiwanese Nephrological Soci-

ety, the doctors acquired two heaters for the clinic and from then on

patients were advised to use these during dialysis. In this instance, the

contingent hybridization of a patient was easily articulated with the

local dialysis enactments.Here the patients passage through the moment of hybridization was sur-

prisingly smooth, but this was not always the case. Mrs. Lai found it slightly

difficult. Let us go back to her interview.

After explaining her condition to me, Mrs. Lai turns to a nurse nearby and

asks how much water has been drained. The nurse reads from the machine,

says: two kilos already and half a kilo to go. Mrs. Lai thinks for a bit and

replies: no, not so much, only 0.2 (kilogram) more. I told Ms. Wang thatI dont want so much to be drained out. Let me check. The nurse checks

Mrs. Lais medical record against the display on the machine, and says:

your target dry weight is 55 and today you weighed 57.5, including the

meal you had. It is 2.5. You dont want so much to be drained? Are you feel-

ing your blood pressure is down again? Lets have a look. Mrs. Lai says

she is fine and just does not want to be so dry. The nurse takes Mrs. Lais

blood pressure and says: 130 over 78, it is good. OK. Ill reduce the

amount I drain, but next time you should discuss with the doctors if you

want to change the target weight.

When the dialysis session finished Mrs. Lai decides to discuss this with the

doctor on duty, but she does not go immediately. She turns her back to the

nurses, drinks some water, and swallows a small pack of brown powder.

When she asks the doctor to increase the dry weight, the doctor asks: do

you feel too dry, any cramp, or low blood pressure after dialysis? Mrs.

Lai says: Nothing. My Chinese medical doctor wants me do so. Why?

asks the doctor. Mrs. Lai says: He thinks that my lung meridian is weakened

partly by the drainage of water on dialysis. So I think I should try. . . .I see. The doctor interrupts while scanning Mrs. Lais medical record.

Obviously he does not follow her. He continues: Mm, your chest X-ray

taken three months ago shows that you heart lung ratio is good. Ok, increasing

a little doesnt matter. I will change the order. Be careful with Chinese

medicine, if you have any questions, please discuss these with us. . . .

Lin 431



14/25

On our way out of the doctors office Mrs. Lai tells me that she does not

think the doctor was listening to her: but this doctor is ok, so I told him what

I was doing and I had my way. This helps my lung meridian. Being drained

completely dry makes it idle and means that it loses function. . . .

I ask why she turned around to take the powder. She says: I turned my

back, because some nurses are annoying. They think Chinese medicine is

harmful; they always say some people take poisonous Chinese medicine

and end up on dialysis. . . . I dont blame them. I agree that not all

Chinese medical doctors are capable and people abuse Chinese medicine.

Mine is pretty good, he can understand the blood examination report too.

I always bring my monthly report to him. . . . So I have to cheat some-times. They have their rules, but I have my tactics. For example, my Chi-

nese medical doctor wants me do dialysis at a higher temperature to

improve my phlegm-dampness, but nurses are reluctant to do so. When

I first asked they said that a lower temperature keeps you blood pressure

up. . . . So I learnt and told them that I was cold . . . They bought it and

increased the temperature. It saves trouble.

Unlike Mr. Lee, in order to follow her alternative therapy Mrs. Lai had to use

tactics. Mrs. Lais practices interfered with essential parts of dialysis includ-ing setting the patients target dry weight and temperature of dialysis, all

done in a setting including machines, a process of clinical treatment, calcula-

tions in medical records, and regular monitoring including hourly blood pres-

sure and six-monthly x-rays. Tactics were necessary, because Mrs. Lai was

mixing incompatible Chinese medicine with biomedicine, and enactments

ofchi with biomechanical bodies; more correctly, she was introducing sub-

altern Chinese medicine into a dialysis clinic, one of the strongholds of hege-

monic biomedicine.Despite the challenges, Mrs. Lai had done so not by provoking, but by

negotiating with, lying to, and hiding what she was doing from medical

personnel. For instance, when she turned her back and complained being

cold, she quietly built herself a Chinese medical world in the biomedical

clinic. This was how and where she bypassed the incompatibility, and

hybridized therapies, not permanently and comprehensively but temporar-

ily and locally.

This scenario further reveals the specificity of subaltern agency in con-

trast with that of entrepreneurial agency. An entrepreneur hybridizes and

translates the heterogeneous agency of others in order to raise the world

and innovate (Latour 1983; Akrich, Callon, Latour 2002a, 2002b). But

subaltern agency manages hybridized coexistence precisely without inter-

esting others. The subaltern does not want to rearticulate the incompatibility




15/25

or challenge biomedicine; neither was of concern to Mrs. Lais, and they

were in any case way beyond her capability. What she wanted was both dia-

lysis and phlegm-dampness. Moreover, unlike an entrepreneur who wants

to interest others in order to have them do things for him or her, Mrs. Lai

learned from experience that it was futile to inform the annoying nurses

(though she still tried to explain to the ok doctor). Overall, however, she

normally avoided interesting medical personnel and kept herself unno-

ticed so as to find ways to have the dialysis establishment do things for her.

Take changing the temperature setup for example. In standard dialysis prac-

tices, lowering the temperature shrinks a patients blood vessels and pre-

vents blood pressure from falling. However, in Chinese medicine,increasing the temperature facilitates the circulation of chi and blood in the

body, and eases the deteriorating phlegm-dampness somatotype. The con-

tradictions were bypassed, as Mrs. Lai did not ask for a higher temperature

by saying that my Chinese medical doctor says that this is needed, and

enacting herself a follower of Chinese medicine who was challenging bio-

medicine or at least disturbing routine practices. Instead, she lied and said,

I am cold. By doing so, the situation, the nurses, and even the dialysis

machine were all displaced and hybridized together: the potentially antag-onistic situation was rendered routine, the nurses following biomedical sti-

pulations enacted Chinese medical practices, and a dialysis machine that

was supposed to warm up a biomechanical body facilitated the circulation

of chi. Displacing and hybridizing alternative practices without being

noticed, this illustrates just one of the tactics subalterns employ to enact

alternative agency in the intersection between the hegemonic and the

subordinate.

Restabilization: Displace the Trope of Trial and

the Situation

The failure of a fistula rendered the agency of dialysis patients indetermi-

nate, and problematization, distribution, and hybridization followed. But

as we have just seen, unlike entrepreneurs, patients did not challenge the

biomedical world but managed to sustain their alternative subaltern world

alongside or within one that was hegemonic. This process was a medical

as well as an ontological passage through which patients brought their par-

ticular ways of doing dialysis, and hence configurations of agency, into

existence. Some, like Mr. Lee, might find it easier to follow enactments

allied with biomedicine, but others such as Mrs. Lai discovered that their

alternatives were not compatible with the configurations of dialysis.

Lin 433



16/25

Depending on how well they managed to resist the challenges of biomedi-

cine, the alternative agency of such patients might or might not be sus-

tained. This highlights the last but probably the most critical moment in

the process of restabilization.

The stabilization of agency is essential in the translation model and is

achieved in trials of strength:

[D]epending on the trials of strength, spokespersons are turned into subjective

individuals or into objective representatives. Being objective means that no

matter how great the efforts of the disbeliever to sever the links between you

and what you speak for, the links resist. Being subjective means that whenyou talk in the name of people or things, the listener understand that you rep-

resent only yourself. (Latour 1987, 78)

This model is still present in Latours more recent writing:

Without accounts, without trials, without differences, without transformation

in some state of affairs, there is no meaningful argument to be made about a

given agency. (Latour 2005, 53)

However, patients find it difficult and unwise to draw attention to their

alternatives, and certainly do not want to push matters to a trial. In prac-

tice, as we know from Mrs. Lais case, patients avoid a head-on confronta-

tion. Callon and Rabeharisoa (2004) have reported a similar tension in the

case of a patient who refused to engage with a medical network and a socio-

logical interview as he enacted his agency.

This highlights the specificity of entrepreneur agency in the translationmodel. Enduring trials in order to decide the spokesperson may be impor-

tant in science or innovation (Latour 1983, 1987; Akrich, Callon, Latour

2002a, 2002b). However, in medical practices such as dialysis, the main

preoccupation of all concerned may not be putting each other on trial, but

to keep the routines and the lives of the patients going (Berg and Mol

1998). Though clinical situations change from time to time, trials are

unusual.

But the tension is always there, and occasionally when a patient

determines to speak for himself or herself the peace is disturbed. This

was what Mr. Chen taught us. Unlike most patients concealing their

alternative therapies, Mr. Chen was so eager to spread the good news about

helpful religious therapies that he edited a pamphlet about his way of dealing

with dialysis related problems and distributed it widely among patients.




17/25

Mr. Chen also relentlessly put his ideas into practice. Here is one occasion

I witnessed.

I am interviewing Mr. Chen in the clinic. Recently, Mr. Chen has reduced his

frequency of dialysis from three times a week to five times a fortnight, then to

twice a week. The nurses are angry and worried, but Mr. Chen insists that this

is right. The nurses know that I am interviewing him and we are getting on

well. They ask me to persuade him to change his mind. When I mention it,

Mr. Chen says, I am not doing this blindly . . . . I am trying very hard to

achieve this. My parents gave me my body, and I should not hurt myself.

I carefully evaluate the condition and try to transfer from dialysis to other

ways of doing things gradually.

According to him, such therapies and dialysis are like cars. Living a life

in the world is like taking a ride in different cars. Doing dialysis is riding one

kind of car and other therapies are others. . . . What is important is that we

know where we are going and are not being confined to the car in which

we are travelling. . . . If we can make the body more accustomed to other cars,

then we wont need dialysis. He does not think very much of biomedicine,

because Its development is based on the sacrifice of other lives, it disturbs

the harmony between nature and the body, and all of these chemical medi-cines are poisonous . . . basically, it is not compatible with the principles

of good knowledge. Since his ultimate goal is to follow good knowledge

in order to improve his sacred heart, while dialysis works for his body he has

to find therapies that he can drive that do not contradict good knowledge.

He is very confident and proud of his achievement.

When we are talking, Ms. Hsu walks by. She stops and listens to us for a

while. Then she interrupts and talks to Mr. Chen: How many sessions are

you doing next week? Mr. Chen replies, Two. I have told the deputy

nurses. Ms. Hsu says, Two! You are risking your life! Your monthly blood

examination report is here . . . . She searches and takes out a paper from the

pile of papers she is holding and continues: See, your uremic level is high

and the potassium and other ion levels are high as well, but others, Hb, Hct,

protein levels are low. You are not having sufficient dialysis and you are very

weak. Eat some meat, vegetables are not enough . . . I will arrange three ses-

sions for you, all right?

Mr. Chen smiles, he says, No, thanks, I am fine. I feel energetic . . . and

everything is going well. I think I only need two. Ms. Hsu says: I wontargue with you any more . . . so long as you take good care of yourself. Then

she turns to me, shakes her head and says: He is so stubborn, and leaves.

Mr. Chen then tells me: You see. Western medicine is obsessed with trivial

things, and doesnt care about the fundamental things. How can you say that

I am not well just by looking at the biochemical test, when I am so energetic

Lin 435



18/25

and able to do more work? My experience and abilities compared to test

results, which do you think is more important and credible?

This was a very unusual event. At this moment, different configurations of

agency were challenging each other; each tried to restabilize itself by pro-

blematizing the other. From Mr. Chens perspective, the indicator of his

agency was not a blood examination but rather the fundamental daily

experiences of feeling energetic and sensing that everything was going well.

In order to keep his fistula, and even better his health and sacred heart, well,

what he should enact was not keeping the dialysis schedule or eating more

protein but practicing good knowledge.There seems to have been a trial about the sustainability of the reality

of the sacred heart and Mr. Chens agency going on. The point had been that

when other people had said that everybody had known that biomedical

dialysis was the right thing to do and religious therapies were superstitious,

they had had to make the point. The nurse had done so; she had shown

Mr. Chen his blood test results. This simple action had drawn in widely

institutionalized networks of biomedical practices. In contrast, without sci-

entific institutions behind him, Mr. Chen also had enacted networks of

religious or traditional practices shared by many people by introdu-

cing his experiences in conversations and in his pamphlet.

However, this would have been an unfair trial, not only because Mr.

Chen would have been alone when he was facing the wide institutionalized

biomedicine but also because a biomedical configuration of agency had

been routinely and collectively enacted in the clinic, whereas Mr. Chens

version of reality had only been temporarily enacted in his presence through

the pamphlet. It would have been unfair that most witnesses, patients in this

case, had enacted an asymmetry between questionable superstition on onehand and justifiable, biomechanical biomedicine on the other. This episode

continued and ended a few months later.

When I arrive at the clinic, Ms. Chiu tells me silently: Do you know that Mr.

Chen passed away? He was outrageous. He has only six dialysis sessions last

month. . . ! I was shocked and grieved over Mr. Chens failure to prove him-

self. When the news spread patients and nurses talked about Mr. Chens early

death. They say, he shouldnt have done dialysis that way . . . , he was so

superstitious. . . , I knew that he was risking his life. . . . Mr. Lee and Mrs.

Lai both agree with this.

Was this a moment of truth that revealed the result of the trial about

Mr. Chens agency? Now, the nurse was the one still speaking. According




19/25

to the translation model, the trial had turned Mr. Chen into a subjective rep-

resentative of an unsustainable therapy and Ms. Chiu into a spokesperson of

objective biomedicine. But, as I have suggested above, there is another way

of reading this. It can be understood as an example of the epistemic violence

of hegemonic biomedicine and the politics of representation in conceptua-

lizing agency. Donna Haraway has warned us that the agonistic scenario of

a trial reflects a winners world view, and says:

The story told is told by the same story. The object studied and the method of

study mime each other. The analyst and the analysand all do the same thing,

and the reader is sucked into the same game. (1997, 34)

The story of Mr. Chens irrational superstition told by the biomedical per-

sonnel and Mr. Chens unaccountable agency retold in an account that treats

this as a trial further exemplify agency, precisely as the outcome of a trail.

But what if this is not the only thing going on? What can we see if we do not

follow the representations of the medical personnel? What other modes of

agency are available?

The trope of the trial portrays a world on the model of an amphitheaterwhere ambitious combatants fight each other until the last man/woman

stands. It enacts a particular situation with dualistic moral statuses, win-

ner/loser and subject/object, for the participants. Perhaps, this is the case for

science (though there is work that suggests otherwise), but it is certainly not

what happens in clinical treatment (Mol 2002). So how might we think of

this? Haraway talks of diffraction. She suggests:

Diffraction does not produce the same displaced, as reflection and refrac-tion do. Diffraction is a mapping of interference. . . . A diffraction pattern

does not map where differences appear, but where the effects of the differ-

ences appear. (1992, 301)

Paraphrasing Haraway, this diffraction of patients agency does not end up

with an objective world of a winner left standing among the losers. Instead,

knowledge is situated: a world must always be articulated, from a partic-

ular point of view (1992, 314). What is this situation from the patients point

of view? Certainly, biomedical truth is sometimes enacted in clinical

treatment; in the practice of finding out what went wrong; and in describing

problems and explaining examination report to patients. While pursuing this

objective truth, as Latour suggests (1993), complex agencies are first

hybridized and then purified in order to be verified independently in

Lin 437



20/25

carefully coordinated situations of trial, and then a specific, purified version

of agency is enacted as if it were pure from the very beginning. However,

patients do not necessarily care about truth/fact (Mol 2008, 42-65). For

instance, those pursuing alternative therapies care more about sustainabil-

ity; when their fistulas, bodies, or something else goes wrong, biomedicine

has only unsatisfactory solutions. Whether it is a functional supplement,

Chinese medicine, or spiritual therapies, patients are forced to search for

various alternatives that have proven to be useful but do not necessarily

comply with biomedical truth.

Therefore, to understand these patients agency, we need multiple

visions, exploring both biomedical representation of evidence and facts,and patients alternative enactments which are hiding away from, under-

represented or unrepresentable in biomedicine but are essential in sup-

porting patients accounts of themselves and their lives. Thus Thompson

writes:

agency here refers to actions that are articulated to people or claimed for one-

self, that have definitions and attributions that make up the moral fabric of

peoples lives, and have locally plausible and enforceable networks ofaccountability assigned to them. (2005, 181, italic original)

So, what happened to the configurations of agencies in the revelation of Mr.

Chens death? First of all, it was about Mr. Chen. Ms. Chiu was reenacting

Mr. Chens agency. Ms. Chiu represented Mr. Chens practices as outra-

geous and reminded patients that alternative practices were potentially

lethal; Mr. Chens alternative practices were reenacted as the disabling

enactment of biomedical agency, hence contributing to the loss of Mr.Chens agency. Second, it was about biomedicine. As they normally do,

dialysis personnel enacted what had happened in a specific way in order

to demonstrate the superiority of biomedicine over alternative therapies.

This repaired the disrupted routine and resumed the disturbed biomedical

configuration of agency. Thirdly, it was about the other patients. If biome-

dicine reclaimed its hegemony over alternative therapies in such a dramatic

situation, some patients might follow the warning and gave up their alterna-

tive therapies, while others, like Mr. Lai when being warned about Chinese

medicine, would not confront the dialysis personnel but simply concealed

their practices more carefully.

In this sense, patients were rendered compliant, continued to dissimulate,

and were only rarely assertive. Their counterparts, the nurses, and doctors

were alternatively helpful, annoying, or ok most of the time, but also




21/25

proactive in the context of such a dramatic event. Taken together they were

enacting many different configurations of agency, since the changing situa-

tions rarely ended up as trials, and there are much more than winners or

losers in the dynamics of moral status. Such was the enactment of subaltern

agency in the unfolding displacements.

Finally, in addition to changing ANTs account of subaltern agency, this

displacement interpretation provides alternatives to Spivaks theoretical

skepticism about the inaccessibility of subaltern agency. To think of subal-

tern agency as displacement is to align with Spivaks argument. But there is

a major difference too. Spivak suggests that the subaltern cannot speak; the

hegemonic representations speak for the oppressed and render her as theinaccessible Other. Thus, though the position of noncompliant patients is

very different from that of Hindu widows, both are subordinated by hege-

monic representations that speak for them: for widows, there are Western

intellectuals, nationalists, and imperialists; and for patients, there are pro-

fessional power, the cultural imperialism of biomedicine over Chinese med-

icine, and the domination of biomechanical over chi and spiritual

understandings of the body. However, instead of assuming the subaltern

wants to speak and wondering whether the subaltern can speak against thehegemonic, what this article has shown is that patients displace their prob-

lems rather than speaking for these, the therapies, themselves, or the situa-

tions they find themselves in. The elusive, unrepresentable subaltern silence

should not be understood as a failure. Rather, it counts as a remarkable

achievement.

What are the implications of recognizing this silence as an achievement?

Does not being silent simply help sustain the status quo of hegemonic

practices? Can displacement as agency make any difference to the positionof the subaltern? Unlike ANTs notion of translation and Spivaks concept

of delegation, the displacement model highlights the paradox of representa-

tion in the making of subaltern agency. This is not entrepreneurial agency.

Patients cannot afford to represent their alternative practices, challenge

hegemony, and claim credit for doing so. The many displacements and

achievement of invisibility as they achieve agency are precisely the condi-

tions of possibility needed to sustain life in the context of dialysis. This is

practically crucial. But analytically, what is most remarkable is that patients

resolve their problems by adapting dialysis practices to those of alternative

medicine or vice versa as if they have made no difference at all. Thus pro-

posing the displacement perspective is not to translate or speak for the

silence of the subaltern; instead, it is to envision multiple possibilities, to

find ways of joining force with the subaltern, and of realizing alternative

Lin 439



22/25

ontologies, institutions, and subjectivities in the making and remaking of

day to day realities.

Conclusion

This article has adopted an enactment approach to explore the practices of

dialysis and elaborate an alternative displacement framework of agency

from the point of view of the subaltern. The cases of dialysis patients

suggest that patients have to go through a process of problematization,

distribution, hybridization, and restabilization, in order to sustain the

coexistence of their alternative practices with dialysis. The article showsthat patients displace the problem, the therapies, themselves, and their

situations in situated enactments. The shifting configurations of patients

agency in these moments are elaborated to interrogate the process of

problematizing, interessment, trial, and representation in a translation

model.

Unlike entrepreneurs, patients are subordinated to hegemonic transla-

tions by medical personnel, biomedicine, and a positivist biomechanical

understanding of the body. The translation model that prioritizes the tropeof trial and contest for representation is unable to recognize patients elusive

displacement in making their agency. Unlike entrepreneurs who transform

the world by interesting others, enduring trials, and becoming spokesper-

sons for all, those patients who manage to displace and sustain the coexis-

tence of multiple worlds avoid interesting, still less confronting, the

hegemonic actors and claiming representation for themselves. This article

proposes displacement as agency as an alternative. But this is only a

beginning.The translation model conceptualizes particular forms of entrepre-

neurial agency in epic moments of world transformation or in fields that

prioritize representation. But given the ever changing intersection of

multiple worlds, what I have written explores the paradox of represen-

tation in making subaltern agency and suggests that different forms of

subaltern agency are made and displaced so as to render themselves unre-

presentable. If this is the case, it is vitally important to explore the various

patterns of dynamics that arise in different subaltern contexts; examine the

different tactics subalterns devise to manage the intersection of multiple

worlds and the consequences for their agency; and to consider the possible

ways in which these patterns and tactics teach us to diffract our under-

standings of the multiple forms of agency that make up our world. Such

is the challenge.




23/25

Acknowledgment

The author would like to thank all the interviewees for their kind help with thisstudy. The author is grateful to late Susan Leigh Star, John Law, and the anonymous

reviewers for their comments and recommendation on drafts of this article. The

author also appreciates financial support from the National Science Council (95-

2412-007-005-MY2). The article is entirely the responsibility of the author.

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research,

authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research,

authorship, and/or publication of this article: The research was supported by the

National Science Council (95-2412-007-005-MY2).

Note

1. Haemodialysis treatment is based on an osmotic apparatus that extracts excess elec-trolytes, water, and uremic waste from the body of a patient of End Stage Renal Dis-

ease (ESRD) by filtering the blood drained out from an arteriovenous fistula. A

fistula is constructed either by connecting to an artery and a vein or by implanting

artificial tubing in the arm.

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Author Biography

Wen-yuan Lin is an Associate Professor in General Education at the National

Tsing-hua University, Taiwan. He publishes on issues in patients practices, change

of medical regime, users in technological innovation, and empirical ontology. He

serves on the Editorial Board ofTaiwanese Journal for Studies of Science, Technol-

ogy and Medicine.

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Science Technology & Human Values 2013 Lin

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