Distributed sleeping and breathing: On the agency of means in medical work

Without the stethoscope, the scalpel, the thermometer or the patient file, medical work would not be what it is today. This chapter will concentrate on the work of doctors, more precisely on the anesthetic practices during surgical operations and on the use of technical means for administering and monitoring narcosis. It will focus especially on the use of tools and machines in everyday routine medical practice. Work, it is argued, is always mediated by artifacts – by tools and machines – yet these instruments cannot be understood solely from a utili­ tarian perspective as mere means to ends. Instruments, it is argued, transform and shape the way medical work is carried out. However, this transformation cannot be simply reconstructed in terms of either technological determinism or social determinism (cf. MacKenzie and Wajcman 1999). This chapter seeks to conceptualize the agency of means in medicine by comparing different arrange­ ments of diagnostic and therapeutic technologies. The agency of medical instruments will be analyzed as they emerge within embodied and technically mediated relations between doctors and patients. This chapter is less concerned with the question of what the actors do with the arti­ facts or vice versa than with the extent to which both enable and constrain the actions found in everyday medical work. In early phenomenological and prag­ matist reasoning, both Martin Heidegger (1967 [1927]: 76) and John Dewey (1958 [1925]: 121) stressed that the analysis of tools and instruments is an anal­ ysis of references and relations. Tools are not understood as mere means to ends but as constitutive elements in the relations between humans and their environ­ ment. As such, they transform both constituent parties by mediating the relations between them. This line of thought has been critically extended by recent discus­ sion on the agency of technical means in science and technology studies (STS). For the purpose of this chapter, I will take up the distinction between intermedi­ aries and mediators put forth by Bruno Latour (2002) as well as the concept of distributed agency1 developed by Werner Rammert (1998, 2008). Medical work, like most other types of human action, is mediated action, i.e., action that is distributed between doctors, patients and artifacts. Subsequently, medical diagnosis and treatment are composed of distributed yet interlockingforms of human and technical agency. Based on this deeply composite under­ standing, my analysis of medical work lays out a conceptual approach to under­ standing distributed agency, and empirically traces the interdependencies of human and technical agency in anesthetic practice. In the empirical section of this chapter, I will trace the distribution of agency in different constellations of administering anesthesia during surgical operations. In particular, I will analyze how sleeping and breathing become distributed between doctors, patients and tools. The research presented in this context is based on ethnographic fieldwork in three hospitals and the observation of 67 routine operations. In addition to participant observation and video analysis, video elicitation interviews were conducted (cf. Schubert 2006, 2007, 2009). For the purpose of this chapter, I will sketch out the agency of diagnostic and therapeutic tools in anesthetic practice and will mainly be concerned with the difference between simple tools, like the stethoscope, and more advanced tech­ nologies, such as anesthetic monitoring.