1. Evidential Matter(s)
Not only is everything changing, but all is flux. That is to say, what is is the process of becoming itself, while all objects, events, entities, conditions, structures, etc., are forms that can be abstracted from this process.
David Bohm, Wholeness and the Implicate Order
Medicine is a heterogeneous coalition of ways of handling bodies, studying pictures, making numbers, conducting conversations. . . . There is multiplicity even inside medicineâs biomedical âcore.â
Annemarie Mol and Marc Berg, introduction to Differences in Medicine
After gradual loss of his mobility and speech, on June 17, 2014, my paternal grandfather died of multiple system atrophyâa rare and relatively mysterious degenerative disease that affects the brain. Fewer than twelve months later, at only age fifty-nine, my uncle died of an aggressive form of brain cancer. As I grieve for my grandmother, Bernice, who in one year lost both her son-in-law and her life partner of five decades, I am struck by the degree to which medical professionals struggled to name and navigate our loved onesâ illnesses. Because disease seemed to sneak up on my grandfather and uncle and then slowly whittle away at their brains and bodies, Iâve become hyperaware of my fatherâs tendency to repeat a story for the second or third time. When dad suffers a minor injury now and then because of what appears to be mere clumsiness or overexertion, I worry. Concerned that his forgetfulness, muscle pulls, and pain might be signs or symptoms of something ominous, I try and take comfort in recent medical tests and scans that indicate dadâs brain and body are in pretty good shape.
Uncertainty posed by the ambiguous space between living and dying is mitigated, albeit only in part, through medical evidence. But how are evidential worlds assembled from bodies in perpetual flux? From where does medicineâs evidential weight hail? What protocols and procedures elevate everyday biological activities to positions of argumentative authority? This book seeks answers to such questions through an exploration of the backstage, behind-the-scenes biomedical practices that materially render medical evidence both visible and actionable. Bodies in Flux is inspired by medical professionalsâ success with and failures at navigating not knowing. Each chapter investigates one of four specific scientific methods for negotiating medical uncertainty in cancer care: evidential visualization, evidential assessment, evidential synthesis, and evidential computation.
Defining and diagnosing disease is a kind of quixotic empiricism. It requires taking whatâs known now and making best guesses about whatâs to come. Yet, as physicist and philosopher David Bohm (1981) argues, âall is fluxâ (61). Inspired by partnerships with nature, premodern medical and scientific practitioners once used astrological evidence to manage bodily flux. For example, constellations once aided in predicting astral circumstances of birth, controlling parts of a body, and determining when and where to let blood or take medicine (French 2003, 132). Todayâs attempts at managing bodily flux involve monitoring corporeal symptoms and modeling risks. From telescopes to stethoscopes to microscopes, biomedical projections have always resulted from human and nonhuman partnerships. The always already collaborative nature of attempts at forecasting corporeal futures complicates contemporary biomedical practice and precision. Bodies in Flux explores such complications.
I invoke âfluxâ not only in reference to cancer careâs corporeal contingencies but also to orient readersâ attention toward scientific indeterminacy (Barad 2007)âthe kind of contingencies and indeterminacy that Heraclitus may have had in mind when he famously declared the impossibility of stepping into the same river twice. As a concept, flux highlights the evidential complexity of being (a body) in the world. In rhetorical theory, flux counters the notion that rhetoric, and decision making in particular, consists of discrete and autonomous elements such as audience, purpose, or context. Contesting the reductive nature of a or the rhetorical situation, Jenny Edbauer (2005), Louise Weatherbee Phelps (1991), Laurie Gries (2015), and several other rhetoric scholars have advocated for an ecological view of rhetoric that situates suasive activity within (and because of) a âwider sphere of active, historical, and lived processesâ (Edbauer 2005, 8). An ecological model of rhetoric characterizes ârhetoricâ as a verb. A performance. A constant process of unpredictable unfolding. To study rhetoric, therefore, is to study flux and flow. To study rhetoric is to explore processes of becoming (Bohm 1981).
In the following chapters, I trace processes of becoming in the biomedical backstage. That is, I trace how modern medicine does rhetorical work. To do this, I identify and analyze biomedical practitionersâ material-discursive negotiations with matter, movement, and time. I do so motivated by the troubling awareness that well prior to medical practitionersâ attempts at understanding my grandfatherâs, uncleâs, and fatherâs corporeal conditions through freeze-framed abstractions (such as medical images or blood tests), processes deep within their bodies were and are always at work. Material actionsâsome seen, some unseenâperform our bodily being long before doctors even know to look.
Bodies in Flux is about and for those who compose, communicate, contend, and cope with biomedical evidence as material made to mean. Each chapterâs investigation of medical practitionersâ attempts at managing bodiesâ inherent indeterminacy is written with patients, practitioners, policy makers, technical communicators, rhetoricians, medical humanists, and science and technology scholars in mind. Exigencies for a book about how biomedical evidence is made to mean are abundant. In response to evidence-based medicineâs fetishization of medical evidence many wonder: Whose evidence? What counts as evidence? And how is evidence tallied and made to matter? Commoditized, direct-to-consumer genetic testing kits and government-mandated electronic medical records invite additional scrutiny: Who owns my medical evidence? Who should or should not have access to it? Evidential complexities such as these have implications not just for decision making. Evidential complexities such as these also have economic and ethical effects.
The rate of women in the United States choosing to undergo what is now referred to as a âbilateral risk-reducing mastectomyâ has increased by 50 percent in just the last five years. As I write this, these rates, along with what is colloquially referred to as the âAngelina Jolie effect,â have sparked a cultural firestorm of debate about medical certainty, womenâs choice, and biomedical ethics. In an effort to demystify (if not normalize) the procedural and surgical implications of her decision to undergo a preventative double mastectomy, Jolie (2013) detailed three months of medical procedures and experiences in a New York Times op-ed. Since the op-edâs publication, debate has ensued about whether testing positively for BRCA1, a genetic marker that when present increases a womanâs risk of developing breast and ovarian cancer, ought to be grounds enough for a doctor to recommend preventative or ârisk-reducingâ surgery on otherwise healthy bodies. Jolieâs mother died of cancer at only fifty-six years of age. Presumably, Jolie was well versed in statistical probabilities associated with the likelihood that she, too, would suffer a similar fate. For many women in Jolieâs predicament, personal experience and statistical probabilities are the only evidences they have to go on. I invoke the Angelina Jolie effect here not as an endorsement of her choice but to draw readersâ attention to the complexity of weighing evidence against perceptions of risk when making medical decisions.
Regardless of how readers view Jolieâs (no doubt privileged) choice to undergo preventative surgeries, her assertion about how cancer evokes a âdeep sense of powerlessnessâ likely resonates among readers from every socioeconomic status. The powerlessness caused by cancer is pervasive. Genetic biomarkers, statistical analyses of survival, and characterizations such as âbest practiceâ or âstandard of careâ are used routinely in cancer care, but are, by and large, mysteries to those who are unfamiliar with such specialized practices and discourses. We can assume that, in conversations with her doctor, Jolie was provided with accurate and useful information about her diagnosis, prognosis, and options for treatment. Bodies in Flux augments and perhaps supplements such private, doctor-patient conversations and attends to the methodological materiality associated with doing evidence-based cancer care. Mindful of the millions of people who live in a persistent state of prognosis (Jain 2013), I highlight how, in evidence-based medicine, methods materialize matter in meaningful ways.
After nearly a decade of studying evidential construction in the biomedical backstage, I have identified four specific methods with which medical professionals attune to corporeal flux in cancer care: evidential visualization, assessment, synthesis, and computation. To illustrate, consider the backstage, material-discursive labor that had to take place prior to my uncleâs official cancer diagnosis. First, his disease was visualized. To do this, doctors worked with a host of technologies to capture, quantify, and interpret my uncleâs body data (e.g., tumor size and placement, additional health concerns, comorbidities). Second, medical professionals assessed these body data. They relied on statistical calculations of survival by comparing previous patientsâ experiences to my uncleâs unique disease experiences. Third, doctors reasoned about possible prognoses and treatment options by invoking standardized guidelinesâguidelines that were produced from syntheses of previous patientsâ body data. And to better understand the genetic complexities of life-threatening diseases like my uncleâs, medical professionals perform computational analyses of similar patientsâ DNA. By the time any of these evidences are âaccommodatedâ to patients and their care networks (Fahnestock 1986), details surrounding the material-discursive design work I just described are black-boxed (Latour 1987). For Latour, âblack boxâ is a construct âused by cyberneticians whenever a piece of machinery or a set of commands is too complexâ (2â3). Black boxes collapse complexity into mere input and output. Black boxes coalesce disorder into something that âresembles an organised whole. . . . When many elements are made to act as one, this is what I will now call a black boxâ (Latour 1987, 131). Bodies in Flux props open such cancer-care black boxes. It unearths scientific methods that are used to make evidence matter and mean in the biomedical backstage.
Methods Matter
Over the last three decades, the phrase âevidence-based medicineâ has become a discursive marker for rigor and reliability in biomedical practice. Specifically, evidence-based medicine is defined as âthe conscientious, explicit, and judicious use of current best evidence to guide decisions about patient careâ (Sackett et al. 1996, 71). Before the practice was referred to as evidence-based medicine, randomized and well-controlled clinical trials were called critical appraisals. When Gordon Guyatt made programmatic changes to McMaster Universityâs medical school in the 1990s, he advocated for educational instruction and practices that placed proven evidence (as could be supported through critical appraisals) ahead of expertsâ authoritative experiences and opinions. Critical appraisals acted as guidebooks by granting practitioners a sense of randomized trialsâ methodological rigor. Guyattâs revisions meant that methodological rigor now trumped clinical expertise. Evidence-based medicine soon displaced expert-based medicine, and young physicians who embraced randomized controlled trialsâ methodological superiority and evidential authority soon found themselves empowered.1
While some regard evidence-based medicine as a recent phenomenon concomitant with so-called scientific progress, for reasons I will soon describe in greater detail, I argue that medical practice has always been evidence based. Evidence-based medicine is not just an insistence on using evidence to make decisions. Medical practitioners have for centuries used evidence to make decisions. Rather, implicit in the era of evidence-based medicine is an agreement among contemporary medical practitioners that methods matter. That is, evidential worthiness and weight in modern-day biomedical practice hinges on methodological transparency and quality.
To demonstrate that contemporary evidence-based medical decision making is just as complicated as it ever was, scholars from various disciplines have sought to account for the role of affect, logic, intuition, persuasion, and experiential knowledge in medical practice (see, e.g., Denney 1999; Derkatch 2008; Graham 2011; Grossman and Leach 2008; Lambert 2006; Little et al. 2002; Mykhalovskiy and Weir 2004). Some scholars (in particular, those who characterize their work as medical rhetoric) have conducted important research about how evidence and expertise are leveraged during decision making (e.g., Charon and Wyer 2008; Derkatch 2008; Graham and Herndl 2013; Hikins and Cherwitz 2011; Majdik and Keith 2011; Schryer et al. 2009). But what do we know about the rhetorical design of medical evidences, themselves? What are medical evidencesâ material-discursive lineages? Until now, methods by which evidence is visualized, assessed, synthesized, and computed prior to the deliberative decision-making moment have garnered little attention from medical rhetoricians and technical communicators. While scholars in medical rhetoric (myself included) have conscientiously pored over transcripts from impassioned doctor-patient interactions and pharmaceutical policy deliberations, we have remained largely unfamiliar with (if not ignorant of) the evincing methods with and on which those conversations and deliberations are predicated.
As we seek answers to questions about whose evidence counts and what counts as evidence, methods for making biomedical evidence meaningful invite if not require constant critical attention. Examining methods with which medical professionals design evidence draws attention to and demystifies but also makes strange modern medicineâs prophetic practices. As objects of study, scientific methods for navigating medical uncertainty are complex processes of becoming (Bohm 1981). Human, nonhuman, and computational actors collaboratively design the evidence with which decisions are later made. Understanding how evidential materials do rhetorical work in the biomedical backstageâspecifically, how visuals evince, and how evidences are then assessed, synthesized, and computedâmakes for more informed and agential patients, technical communicators, and participants during individual and public policy decision making. I argue that the material-discursive labor required to elevate quotidian biological processes to evidential status is not merely epiphenomenal to acts of diagnosis, treatment, and prognosis.
So, how does backstage, invisible design work render the argumentative grounds on which a medical decision may be made? To answer this question, each chapter props open the following biomedical, backstage black boxes: pathologistsâ and radiologistsâ methods for imaging cancer; policy makersâ statistical methods for assessing survival probabilities; oncologistsâ methods for synthesizing evidence so that cancer-screening protocols can be established; and direct-to-consumer genetic testing companiesâ computational methods for commoditizing health futures. Examinations of scientific methods for negotiating medical uncertainty build on what Latour (1987) calls contexts of discovery, or science in the making. In each case study, I explore how human, nonhuman, and computational collaborations shape evidences that inform medical decisionsâdecisions that help to allay the deep sense of powerlessness often bred by the threat of disease and diagnostic uncertainty. Understanding this labor is important if medical professionals truly value shared or patient-centered decision making (cf. Charles et al. 1997, 1999). And since multiple publics are increasingly incorporated into democratic decision making about medical and scientific policies, a rich understanding of how evidences are rhetorical constructions might help lessen the degree to which the specter of error-free, scientific objectivity presides over such deliberative events. Finally, disclosing the rhetorical underpinnings of how medical professionals create diagnostic and prognostic order from biomedical chaos might help to advance nuanced definitions for and practices of care (cf. Mol, Moser, and Pols 2010).
Evidential Matters by Way of the Tumor Board
As readers are probably already well aware, cancer care requires collaboration across many fields of expertise. It is not uncommon for a patient to have anywhere from five to ten doctors attending to her case at one time. To improve continuity of care across specialties, medical professionals meet regularly in behind-the-scenes meetings called tumor board conferences. During tumor board conferences, cancer-care professionals from a range of expertise discuss and deliberate about the complexity and contingency of a mutual patientâs case.2 Cases brought to the attention of the tumor board are particularly difficult for one reason or another: Perhaps a patient has several comorbidities or lacks the support network needed for the aggressive treatment their diagnosis requires. Perhaps a patient has more than one cancer, and her oncologist may be unsure about which cancer to treat first or more forcefully. Perhaps the standard of care for a patientâs cancer suggests one particular treatment route, but the oncologist has a hunch that a different route might be more effective in this unique case. Because of cancer-care complexities like these, medical professionals will request that their patientâs case be brought to the attention of their colleagues at a tumor board meeting. My interest in backstage evidential production and each of this bookâs analytic foci emerged inductively from a case study of tumor board meetings.
Inspired by David Olsonâs (1996) World on Paper and Christina Haasâs doctoral seminar on literacy studies, I began the tumor board project in 2005 with a small-scale investigation of what I thought would be the role of the patientâs chart in tumor board meetings. I was surprised to learn that the patientâs physical chart was nowhere to be found during the deliberations I observed.3 What were present during tumor board deliberations, however, were a host of evidences that medical professionals visually, textually, orally, and statistically displayed, described, and debated about. In the absence of a patient chart, each tumor board deliberator enacted a kind of in vivo presence of one or another form of evidence (e.g., the pathologis...