con sus escritos, i por (pie, cíe cierto, la perdería­

All these insights indicate the level o f work that goes into forging an account which both explains the current signs and symptoms the patient exhibits and proposes an appropriate course o f action. It also suggests that medical technologies and devices play a key role in this work. How then should one examine the ways in which these accounts are developed? What theoretical resources exist that will enable the analyst to hold in focus the practical performances o f humans and technologies in anaesthetic work?

One such resource is Law’s (1987) ‘heterogeneous engineering’; in its original form the term was conceived to describe the enrolment and stabilisation o f disparate elements, o f varying degrees o f malleability, into a network. The negotiations, tactics

and relationships that hold a network together give the product o f the network its resultant characteristics:

the stability and form of artifacts should be seen as a function of the interaction of heterogeneous elements as these are shaped and assimilated into a network. (Law, 1987:113)

Law uses the concept o f ‘heterogeneous engineering’ to elucidate the development process o f a large-scale technological artefacts, in this case Portuguese ship building. In this Law acknowledges that:

successful large-scale heterogeneous engineering is difficult. Elements in the network prove difficult to tame or difficult to hold in place. Vigilance and surveillance have to be maintained, or else the elements will fall out of line and the network will start to crumble. (1987:114)

Therefore, ‘heterogeneous engineering’ refers to the activity o f drawing together elements o f the natural, physical, social, and technological and tethering those elements in a stable network so as to produce an artefact, outcome, or effect.

I propose to view the activities o f the anaesthetist as ‘heterogeneous engineering’; drawing together elements into an account that lends a present situation some intelligibility. There are, however, some difficulties in using this term, the first is to do with the notion o f stability. As Law points out, heterogeneous elements do not cohere naturally o f their own accord, they must be stabilised or ‘the network will start

to crumble’ (1987:114). Consequently, a fundamental problem faced by those involved in ‘heterogeneous engineering’ is:

how to juxtapose and relate heterogeneous elements together such that they stay in place and are not dissociated by other actors in the environment in the course of the inevitable struggles (Law, 1987:117).

It is clear to see why in ship building stability is essential, but as Singleton (1998) argues, sometimes it is the instability and ambivalence o f a network that is essential in ensuring the network’s durability. In the case o f the Cervical Screening Programme (CSP), Singleton suggests that only by allowing and accommodating instability at the level o f practice does the laboratory manage to maintain stability at the level o f the CSP. One o f the examples of intractable instability Singleton describes concerns the analysis and reporting o f cervical cells. The laboratory follows guidelines for

recommendations, fitting diagnoses into the categories on the report cards. However, detecting the degree o f abnormality present is not as straightforward as presented by the government and the public CSP. The changes in the cells vary beyond the classifications presented on the report cards and the significance o f the changes can also have a variety o f meanings. The laboratory workers accept this uncertainty as part o f their role and ambivalently state that ‘it is influential’ but that ‘in reality it does not make a lot o f difference’, the difficulty generally being in charting the difference between ‘mild’ and ‘moderate’ changes (Singleton, 1998:94).

In his analysis o f medical decision making Berg (1992) also indicates why stability need not necessarily be a criteria for the success o f ‘heterogeneous engineering’; he

argues that a problem is solvable when a doctor is able to propose a ‘disposal’, meaning a limited set o f actions sufficient to answer a specific patient problem. This does not mean, however, that the patient’s problem is relieved, according to Berg, what matters is that the physician knows what to do next. This implies that the accounts anaesthetists produce need not hold indefinitely, only long enough to direct the next action, after which further elements may be incorporated that will reconfigure again the account and suggested actions.

Berg empirically demonstrates how historical information and examination results, organisational practices, time, and disposal options all mutually interact and are reconstructed in the light o f one another. He argues that no single element is more fundamental than the others, that the elements reciprocally shape one another and are themselves moulded in the process. As Berg tells it, accounts are continually

realigned to match an evolving clinical picture, an account only has to endure as far as it directs the next action. Consequently, stability may not be the most suitable criteria on which to judge the success of heterogeneous engineering in anaesthesia.

A second problem is that in describing the work o f anaesthetists as ‘heterogeneous engineering’ one centres the anaesthetist as the ‘heterogeneous engineer’, the pivotal actor, the planner, the grand designer; incongruous perhaps when approaching decision making as a distributed activity. Timmermans and Berg (1997) note this tendency o f actor-network studies to centre the perspective o f scientists or engineers, and the ‘managerialist’ overtones o f the ‘heterogeneous engineer’ are noted by de Laet and Mol (2000). To criticisms such as these Law (2002) responds that:

we need to hold on to the idea that the agent - the ‘actor’ of the ‘actor-netowrk’ - is an agent, a centre, a planner, a designer, only to the extent that matters are also decentred, unplanned, undesigned. (Law, 2002:136)

and he revisits ‘heterogeneity’ to delineate its various forms. Doing so, he proposes, recovers the ontological heterogeneity of the term; it avoids, he suggests, ‘the flattening effect o f imagining that there is on the one hand a great designer, a heterogeneous engineer, and on the other a set o f materially heterogeneous bits and pieces’ (Law, 2002:136). So, I use the term ‘heterogeneous engineering’ cautiously, wary o f its propensity to centre the anaesthetist as the decision maker, and to invoke

notions o f stability and endurance. Consequently, I will use the term in the sense o f an activity that anaesthetists as well as many other participants o f anaesthesia may engage in, and by balancing this chapter alongside the others I endeavour to illustrate how it is not only the anaesthetist that shapes the course o f anaesthetic practice, many other elements also contribute to this.

Emphasising the fluidity, ambivalence and contingency, rather than the stability, of medical diagnosis and treatment Mol (2000) argues that it is not always possible to make diverse elements align and converge, to achieve a singular coherent narrative. Sometimes, explanations o f a clinical situation will be divergent, some may take priority over others, but the others still exist:

Where in textbooks the various versions of a disease tend to be neatly aligned to

form a coherent overall picture, in practice there are gaps, fissures and frictions between different performances of any ‘one’ disease. It must be easier to coordinate images and stories of a textbook into singularity, than it is to do this

with the materialities of the body and the hospital. For in practice links between various performances are sometimes hard to craft and if they are crafted, even if they go under the same name, the ‘diseases’ diagnosed in different sites, do not necessarily coincide. Instead of being aligned into coherence, in practice reality is multiple. (Mol, 2000:96)

This resonates with my experience o f anaesthesia in which, on occasions, different explanations o f a clinical situation can be devised in retrospect and sometimes even made to cohere but what matters at the time is the clinically situated understanding that suggests a further set o f actions. Perhaps, then, the validity o f an interpretation rests in some part on the ability o f an account, safely, to inform the next set of practical actions.

For Mol, ‘performance’ is a move away from ‘construction’, a term used in the social sciences to stress the historicity and contingency o f the ‘constructed’ entities

(Haraway, 1991b). The difficulty Mol (2000) has with ‘construction’ is that it tends to invoke notions o f endurance, and in Mol’s studies o f the body and diseases such as atherosclerosis, articulations o f atherosclerosis will not endure unless revitalised time and again. Drawing together the pain a person with atherosclerosis experiences and the thickened vessels creates a narrative that will disappear unless it is re-enacted. So there is a parallel here between the heterogeneous engineer and stability, and

constructivism invoking notions o f endurance. Mol addresses this difficulty by using the ‘performance’ metaphor:

It is this requirement of repetitive re-enactment that the theater metaphor

this performance are not invented from scratch every morning: there are scripts available. These may be followed meticulously or fairly freely; they may be modified and changed. (Mol, 2000:86, original italics)

Therefore, performativity suggests that the work o f assimilating a narrative does not begin from the outset over and over, rather it is that once made, those links must be re­ enacted unless they begin to decay. In the case o f anaesthesia an explanatory account, or narrative o f a clinical situation, will hold for as long as it is being performed. Mol (1998) adds that such links are only performed insofar as they suggest an action, something practical. So like Berg, Mol argues that the purpose o f making these links, assembling these heterogeneous elements to tell a particular story and generate a situated interpretation o f events, is to suggest a set o f practical actions.