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Archive for October, 2011

In biomedicine, its history and practice, there are a number of areas, where heteretopological investigation has and continues to aid me in understanding and unraveling problems that involve the concept of the human body, embedded in practices and decision-making: The doctor-patient and the doctor-parent-underage patient interactive situations, the emergence of ADHD as a contemporary disorder, the virtualization of the patient experience, the co-evolution of sociology and biology or the use if medical imaging technologies in diagnosis and therapeutic decision-making.

i. Whose body is it?

The technological gaze in imaging technologies and visual representations of the human body in diagnostics and doctor-patient interaction is constituted by a complex history, which is filled with myths. The introduction and re-transformation (or lack thereof) of this discourse, represented by magnetic resonance imaging (MRI) and functional magnetic resonance imaging (fMRI) is only the latest chapter in along series of discursive transformations, which has been created on the long lasting myth of the possibility of rendering the body transparent (of making the interior and the trope of interioralization [Verinnerlichung] “visibile” and manipulable from the outside: intervention without actually venturing into the interior).

Kelly Joyce seminal historical accounts of the development and the symbolic forms of imaging technology is mostly a history of the development of MRI as a disputed territory over Nobel Prizes and patents. As a surface conflict it is, perhaps, of less importance in comparison to conflicts in clinical practice, where imaging technologies do not actually “produce” images directly; they produce a lot of data, some of which is result of time-lag reaction or discarded and filtered as “white noise”. What is an event, what counts as data is, subsequently, a product of much negotiation:

For example, MR images are computer-generated visual reconfigurations of physical data such as the relaxation times of hydrogen atoms that are found abundantly in the body. These images should truly be called image data because they can conveniently slide between being data or images. Scientists themselves agree that these images are models of reality, which are ‘once or even twice removed from reality’”. (Prasad 2005: 292)

Imaging technology is largely based on the production of numerical data, while the “representational practices” (Joyce 2006) have moved away from numbers and rely on rendered images. Rendering is negotiated and demarcated by parties in control of the context1: The use of numerical data was dropped and images used in diagnostic settings were initially (and remain) largely rendered in black and white for clinical interpretation of data produced by imaging devices (and rendering software) in “medical visual culture” since the early days and unto the clinical use of MRIs – the 1980s – was and remains to be dominated by radiologists (Joyce 2006)2. Radiologist being used to the black and white of X-ray images have been quite effective in defending their dominant position in medical visual culture as the primary “interpreters of images” and, thus, the as authors of “medico-visual” narratives. And even though these images are “mere models”, popular perception between biomedical science and its various publics is that the body is “fully” transparent making diagnostic uncertainty a thing of the past. In actuality, this is a false truth just as there is great difficulty of eliminating “false truths” (Bennett3/Wolford) from the process of of collecting data in visual imaging: Craig Bennett’s now famous test subject in an fMRI study was shown a series of photographs which displayed people in social situations; the positive neural reactions that the pictures elicited in the test subject were measured and “shown” in black white images; the test subject, however, was, first of all, an atlantic salmon, and, secondly, dead

Along the same vein of Bennet’s results and Anne Beaulieu’s seminal “images are not the (only) truth”, Colin Klein concludes with a distinctive twist, that

[n]euroimages – colorized pictures of `brain activity’ – are the most well-known products of fMRI experiments. They are often taken to be evidence for functional hypotheses: that is, evidence that a given brain region plays a particular causal role during the performance of a cognitive task. […N]either neuroimages nor what they depict provide evidence for functional hypotheses. […S]kepticism about neuroimages can be grounded in well-known problems with the use of null hypothesis significance testing (NHST). The problems with neuroimages are thus conceptual, rather than merely practical, and cannot be easily avoided.”

This judgment reiterates the notion of the actual vagueness of images and their dependence on epistemic authorities to count as “medical ontologies”. Charting these quite oxymoronique “dependent ontologies” requires a truly critiquiose understanding (Latour4) and make explicit some of the conceptual mechanisms of how the discontents and deficiencies emerge in practice (Rabinow). Discontents constitutive of the media and practices of imaging technologies among expert groups themselves and between experts and their publics range from the search for MRI’s “true” creators5, to the inclusion and exclusion of numerical data along with visual representation, the choice of color or of no color , and the use of the metaphor of the map, (Joyce, Prasad). Biomedical and cultural narratives in myth and metaphor are inseparable and interdependent in shaping the historicities of experimental sytems (Rheinberger), the epistemic culture (Knorr-Cetina) of clinical practice and the trajectories of patients’ life-courses.

In the primacy of the image of the body (visualization) in imaging technologies historicity becomes focalized (Bal) in

[n]arratives that suggest MRI images provide unbiased knowledge, and thus reveal the truth about the health of a person’s body also erase how referring to physicians – the doctors who initially order the MRI examinations – use medical images in conjunction with other tests to make sense of a person’s situation.”

In other words, the old myth of the body’s transparency attains a phantasmagoric status for the patient’s life-course in the process of decision-making between doctor and patient in a “dialectics of seeing” (Buck-Morss on Benjamin): A patient is shown a black/white image of the inside of their own head and the doctor pointing to certain areas, saying: ‘Do you see these white spots in your brain, that is your MS [multiple sclerosis]. They will increase in number and size.’ Respectively, the patient begins to re-arrange their own identity – past, present, future life-course and biographic narrative of self – according to this narrative structure. This narrative of self, the narrative of the technological and visual regime, the narrative of popular are culture, we find intertwined, as Kelly also shows : With the invasion of visualization into our daily lives through the omni-presence of “cameras, xerox machines, computer visualization technologies”, we witnessed the emergence of a “scopic regime” in the 1980s and 1990s , that was outfitted and (re)furnished with the “twentieth century fascination with the atom”.

The creators of MRI technologies, such as Paul Lauterbur, used a different and more adventurous language than today’s physicians and their patients do, Lauterbur and his colleagues (and rivals) had, perhaps, more room for speaking about the known unknowns (the dragons), then today’s researchers, radiologists, physicians and patients prefer to have – for the myth of lurking chaos, they prefer phantasms in visual regimes that allow them more visual control. Writes Joyce,

the spatial image is [in Lauterbur’s work; A.S.] primarily described as a ‘graphical representation’ that visually shows the spatial distribution of hydrogen nuclei, and its meaning is not is not assumed to be evident.

Lauterbur’s choice of cartographical metaphors stands in sharp contrast to the way physicians and patients now describe the image. Today, language that highlights the relation of the image to pictures of the anatomical body6 are often used in clinical practice [see below on Prasad; A.S.] while language that calls attention to maps and spatiality is less common (…). This linguistic difference occurs in part because of the broader recognition of the centrality of images to contemporary life as visualizing technologies such as cameras, computers, video games, picture-producing cellphones become more common.”

This means, however, that notions of pathology (nosologies), diagnostic decisions and therapeutic regimes, not to mention patient career trajectories and life-course, are less open and spatial than they are closed towards the reference of the relation to a pre-existing anatomical picture:

The sentence “This is my body!” is then visual-narrative re-constructed as this my body in relation to this (perfect) picture: this means that all the lurking chaos, all the dragons are safely avoided, all that is left are known knowns and unknown unknowns.

ii. The body and the atlas: The topology of the cyborg gaze

Of course, this is not the actual situation, because in an actual reality, there are known unknowns, even if we refuse to see them or have become trained not to see them. The production of body atlases as reference material is a great example, because these “atlases” are not really the topologies we, as readers of Foucault and Serres, would hope for. They are, as Amit Prasad argues, produced in relation to a visual regime that Prasad tentatively names cyborg visuality.

While the body is represented in the MRI reproduction of a medical gaze that is similar to previous forms of nondigital visuality, Prasad adds that there is yet also a difference, because, “removed several times” from the actual body, the image configured is rather image data (Prasad).

The (parallactic) removal, that occurs between patient body, MRI machines, rendering software, technician, radiologist, diagnosing physician, and patient, or between a vague and fuzzy7 entity, set software algorithms, standardized and trained gazes, and all sorts of narratives and metaphors, is not even the novelty issue, even if it is a frighteningly wide gap between the public’s illusion that with the existence of MRI the human body has now become transparent (and the idea that these machines can “read thoughts”) and the fact that every expert knows that “one can never be completely sure that what was seen in the images was not an artifact” (and that thoughts cannot and never will be “read”).

The novelty is that there is a level of standardized reference that closes and limits diagnostic trajectories and pathways by use of body atlases, which are, in themselves, man-made myths:

Body atlases, which contain standardized MR and schematic images of the normal and the pathological anatomy, form the ideal-type for cross-referencing during the process of detection of pathology, These body atlases, through experience and instruction, become part of the radiologists memory.”

The tricky part is that these atlases are used to “domesticate” the production of visual regimes and images, as far as Prasad says, and I would go as far as saying that this is true as far as narratives of selves go8. But they are also inherently probabilistic: the structures that an act of imaging produces in the individual body are only with a certain – and often horrendously risky – percentage the structures that can be cross-referenced with the atlas. The “maps” that are produced are “probability” maps: a certain brain structure that shows up in an MRI is the thalamus with 75% probability, nearly 25% probability putamen and to a minute probability something else entirely (Prasad): Uncertain ontologies.

The myth of the “transparent human body” is just that: a myth, in its plainest, common sense.

But the heterotopologists work is not about “debunking”, that in itself does little to facilitate change. We must accept the existence of the myths, and find them and explain how and why they work9:

Images of the body are cartographed to serve as navigational maps to explore human anatomy and detect pathology”

It is telling that Prasad used the map-metaphor that Joyce considers abandoned. I think they are both right: The actual (becoming) entities that are actually in-play would open spaces for this kind of “adventure” (Whitehead), because there are still dragons that can be found lurking in the images, but with regard to the trajectories of the actual practices of health care bureacuracies or research funding, etc., this is not what happens and the notations that say “here be dragons” are excluded from the presentations. In other words, while the images of the body can be manipulated to fit the human myths of the body through the regime of cyborg visuality, the actual body does not dissappear.

To translate this into the deeper theoretical history, our question would be, how can the body be essential and constructed at the same time? Because it isn’t! To try and reconcile these two perspectives would only lead to the old assumptions of dualisms and parallelism10 that plague modern medicine through its reduction to Cartesianism. Respectively, the body has to be considered as a heterotopia and a multiplicity.

Please contact me for full bibliographical references or look up my upcoming book Anthropos’ Scaffoldings

1See for an introduction into some philosophical appraisals and critiques of the role of context in epistemic settings: Butler, Keith “Content, Context, and compositionality” in: Mind and Language Vol. 10, 1995 (2007); Almotahari, Mahrad, Glick, Ephraim “Context, Content, and Epistemic Transparency” in: Mind Vol. 119, 2011

2Although Prasad suggests the existence (and necessity) of contingencies in the appropriation of fMRI in India

4Latour, Bruno “Why has critique run out of steam? From Matters of Fact to Matters of Concern” in: Critical inquiry Vol. 30, 2004

5With prestige, patents and Nobel prizes at stake, the label of the “creator” or “discoverer” was hotly disputed, even though none of these men (the women, who are most certainly part of these “acts of discovery”, remain, as is so often the case “under rug swept”[see the apparent lack of proper mention of Ms. Osborne in the histories of the Hawthorne Studies or Rosalind Franklin’s late fame in the story of the discovery of DNA]) can count as founder of a discursivity.

6Which also means image is put into a temporal instead of a spatial relation to a(n anatomical) picture that has itself been fixed in time. Even though, with regard to the historicity of this development within clinical practice, Joyce warns (and I agree), that it is not a simply matter of temporality as in clinical practices then and now; the crucial point is that it “shows how professional contexts shape which metaphors are used to describe representations of the body.” (Joyce)

7The fuzzy images is milky, therefore, not just lactic, but in removed fuzziness, para-lactic. But it is the mother’s milk of the medical regime, even if just a substitute for the direct forms of anamnesis by a doctor who observes, listens and touches. All removed from the patient: Telemedicine is parallactic medicine, a milk-powder that doesn’t nurture the child with nature.

8“As far as the ‘as far as’ carries” in a shift of perspective and denotation of the length of travel: In iteration of the assertion of how far this statement carries, the mirror-image of the “removal” appears that constitutes the production of the image-data: Even the statements about the parallactic shift must become their own parallax.

9Despite my great respect for the analytical tools of Norbert Elias, I think Benjamin and Foucault understood better than Elias that myths are everywhere and that hunting and debunking myths is in itself the ultimate ever-returning myth (see also on the fallacies of “debunking”, Latour 2004)

10See, again, Mark Johnson’s Meaning of the body, but also: Thure von Uexkuell, Georg Engel, Klaus-Michael Meyer-Abich.

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Over a century ago, the social and cultural sciences emerged in the promise and hope for the possibility of creating a better future for nations, societies, and humanity at large. A Great Depression, two World Wars and the Holocaust could do away with this attitude. It wasn’t until the spirit of ’68 became inextricably linked with the attitude and gesture of social and cultural theorists, and many of the ringleaders of the student revolution settled too comfortably in the seats of their predecessors in business and academia (gosh, finally they, too, had something to fear to lose in power, profit and privileges), and where those weren’t available, they just created themselves whole new layers of administration and governance to fit and rest in (snoring away the chance for true progress). The major domos and dominatrixes of what is often called  and summarily  executed as the Left are, therefore, little better than the 1% Right of Wall Street (which is supposedly ‘occupied’ while I am writing this). A true kunik would say that in fighting over the primacy of who holds the power, the devil’s left and right hand try to suffocate their other’s half of the brain, killing themselves and the rest of body in the process. A kunik would say something like what I just described.  But there are no more Diogeneses of Sinope around, and the cynics of today are usually busy relishing in infertile polemics and the inter-breeding of memes into incestuous meme-plexes that are riddled with inherited intellectual diseases that account for the smattering of knowledge that does suffice for participants to constitutes their ‘expertise’ in current political discourses, the public understanding of science and scholarship, the media, and contemporary financial markets, and this has already begun to infect the ranks among scholars, scientists, administrators politicians, and business managers themselves. Access to resources and to participation in these discourses is no longer made possible by enabled enunciation, but regulated exclusively through negative selections by constraints and polemics.

In holding on to the dogma and the mechanics that all of society is a zero-sum game, an economy of scarcity (and that its opposite could ‘only’ ever be an utopian and impossible notion of ‘superfluousness’,  ‘affluence’ or ‘unlimitedness’) and that the only criterion of progress is growth (mind you, who among the prophets of growth really understands or, if they do, would want their audience to understand the consequence of growth’s main mathematical quality being that it is exponential), the famous 1%, the Leftist Intellectuals, and the many people who are not rich and powerful but believe that one day they will be, have become impotent in the most crucial aspect of the word, namely with regard to the issue of agency: ‘Devoid of potentiality’.

Where is the social theory that would suggest a model of distribution that is based not on the zero-sum game of scarcity and growth but that suggests that the resources in this world are, while not unlimited, more than sufficient for the human race and that within a couple of generations and with a flexible, plastic, and pragmatic approach we could, indeed, achieve a sustainable distribution, without forsaking profit-making to retain a necessary level of asymmetry in the process? What we need is a model of a society and economy of abundance. Abundance, here, means that there is enough for everybody and just a little bit more for those who lust after it, it means we can do anything even if we cannot do everything, it means to make achievement and efficacy the measure of life and put performance and efficiency as the measure of things in their respective, lower place.

Why has scholarship and science not helped us with this, you may ask? And you would be right to do so. Yes, they haven’t done their jobs properly. Or is that just the problem? They have done their job. They have just not followed their vocation (Almost sorry for going all Weberian on you…not). A job is defined by its constraints, whereas vocation means to seek enablement:

Two social researchers of a public-private institute for social research in Germany, I once met with to discuss potential cooperation in research with, who had very little to offer intellectually and no grasp of the historic and pragmatic scope the concepts they were using to constrain and polemicalize me (funny, they were using the word ‘pragmatism’ in my face, claiming how they were following pragmatism and how I should be like them), these two described their (and supposedly my) job to me: Social science has to produce studies that help people who are in positions of influence, such as political parties or business, make their case, and we have to anticipate who will be influential next and make our research count to them by showing their message can be vindicated by research and numbers, that is how we survive and get money.

Another German social researcher put the role that social theorists should play this way, when I was talking to him about how we should try and create theories that could make a difference: Do you want to play politics, he asked  me, you cannot want that, the last time sociologists tried to accomplish something in society was in the 60s, and look what came out of that, no, it isn’t our job to accomplish something in society, or to have influence or make a difference, our job is make social studies of this or that phenomenon in society and not participate.

Another fun game that social scientists play among themselves is to shove responsibilities and questions to other disciplines. In a recent example, in one of the journals run by the American Sociological Association, one author finished an essay by stating about the problem of intersubjectivity that one of its main aspects sociologists shouldn’t even need to bother or talk about, but ‘happily’ leave it to anthropologists.

I do not exactly ‘blame’ Luhmann, but Luhmann’s systems theory and, more importantly, the way it is used by most of his (many) disciples is illustrative of the larger problem (and most social theorists, at least in Germany, seem to have accepted the constraints stipulated by Luhmann). They argue that there cannot be something like a grand-theory of society (as sociologists up to the 1960s seemed to believe), and Luhmann’s theory was the theory that could finally show that to be the case. Luhmann’s theory, in a way, by being the über-theory of theories, thereby itself a grand-theory, was the grand-theory that was none at the same time. It is the last and final grand- theory by doing away with all the others in showing that there can be no grand-theories at all. Great strategy, indeed. In the Luhmannian frame of reference, the best a society can achieve is a self-description. That point, as you will soon see, is crucial. When describing something, you have the opportunity to derive a theory of it, if you have an adequate theory you can use that theory to try and intervene into that something. If you have a comprehensive  or abundantly sufficent description and derived a comprehensive or abundantly sufficient theory, your interventions should achieve what you set out to do.  However, Luhmann’s frame would put a major constraint on this: You cannot have a comprehensive not even a sufficient view, because that would be very much like a view from everywhere (perhaps a view from nowhere, although, I do not think this says much about the view from anywhere, which is what I may be all about, but decide for yourself, how you want to view it). All that you, as a society, can describe is your own(ed) self,  in your own language from your own (singular) point of view.  This puts a limit on your theory and a limit on your interventions.  in other words, because a description of society (at large) is impossible in this current frame of social science, and all that is possible are descriptions of minute parts of our society (looking inwards and regionalizing our societies interior into fragmented interiors)  no theory of society is possible, only theories of the little parts, therefore, societies are too big to interfere in (whereas banks are too big to fail, the failure of societies could not even register on any scale because we are not allowed to have one), we can only micro-manage tiny little parts. If the addition of these parts does not match up with the whole of it, well, bad luck, but, again, what can be done about that, since that is something that cannot be talked about at all and, if remotely possible, we can say it is another mini-part that is the problem and we can ‘happily’ leave that to someone else.

Well, I am not sorry to say that this isn’t a state of affairs that I am content with. I take Pragmatism seriously, and I do not confuse it with a solipsistic-egocentric utilitarianism as some of my, mostly German,  peers do (waddling increasingly towards pear-shape). It is time we take ourselves seriously again and take up the provocations that I have offered here (kunik-ally not polemically). The mission of social and cultural science was never to change the world single-handedly, its original promise was to provide a bridge over the ‘bifurcation of nature’ that the humanities and natural sciences had created in order not to have to speak with one another anymore. But the social sciences are not the child victims of an ugly divorce, even if they have considered themselves to be that for the past few decades and thus gone from pout to tantrum and back again. We, as social and cultural scientists, are not just made to be stepped upon or walked over, matter of factly, we are forged in a matter of concern: Getting from there to here*. Since it seems that at the moment nobody seems to be getting anywhere, we are not doing our job quite right. I think it’s time for us, as social scientists, to have the kid-gloves come off, grow up, and get alive!

*With the concern for references not made clear, the fact of Sloterdijk’s fanship of Diogenes, means I, a mere pawn ripe for sacrifice, cannot spare you the gambit of an architectural joke of moving Underground with a French Tower: Latour goes to prison in England over the Channel, get it?

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