Tuesday, June 16, 2009

Reading :: The Logic of Care

The Logic of Care: Health and the problem of patient choice
By Annemarie Mol

A few years ago, I posted a glowing review of The Body Multiple, Annemarie Mol's book about how atherosclerosis is constructed across the multiple perspectives in hospitals. Mol is an engaging writer as well as a sharp ethnographer and theorist. Even though her books are translated from the Dutch (partly by Mol herself), Mol's enjoyable writing style comes through – she often brings up an observation early on without comment, drops it as she develops the piece methodologically and conceptually, then offhandedly recalls the observation – which suddenly is nudged into a more layered, more multidimensional sense. Then she does it again. It's rather like watching someone laminate a picture under many layers.

Mol continues this writing style, but whereas The Body Multiple is a more or less standard ethnography interpreted philosophically, The Logic of Care is a philosophical argument that draws from Mol's ethnographic data as well as her own experience as a patient seeking care for a chronic condition. This argument is about two logics: the logic of choice that dominates the public and administrative discourse about health, and the logic of care that infuses (some of) its (best) practices (p.11).

Simply, the logic of choice takes individual choice as an ideal – yet this ideal often does not lead to the best results. “I do not question choice in general, but rather the generalisation of choice,” Mol insists in a characteristic chiasmus (p.1). This logic of choice, which is embedded deeply in market capitalism, involves presenting health practices as a choice for the consumer; but some scholars have noted that “making people long for choices and invest a lot in making them, is a disciplining technique”(p.4; cf. Devo, “Freedom of Choice”). And in medical decisions, choice can overburden people, leading to poor choices – and extraordinary circumstances, in which people are not equipped to make choices, are not so extraordinary in medicine (p.6). It's not about whether people can choose, she argues, but rather about situations of choice, in which a specific mode of organizing and interpreting can be applied. And she doubts that the resulting, organized world - “infused with what I call the logic of choice” - actually “offers a way of living superior to the life that may be led in a world infused by the alternative that this book seeks to articulate: the logic of care” (p.7). This second logic does not construct patients as passive: “they do not primarily figure as subjects of choice, but as the subjects of all kinds of activities. The logic of care is not preoccupied with our will, and what we may opt for, but concentrates on what we do” (p.7).

Mol draws contrasts between the two logics, starting with one customer contact point: advertisements. In the logic of choice, the market demands a product: “The market requires that some product (device, plus skills training, plus kindness and attention) is delineated as the product on offer” (p.18). But “Care is a process: it does not have clear boundaries. It is open-ended. ... care is not a (small or large) product that changes hands, but a matter of various hands working together (over time) toward a result” (p.18). Care is not a transaction, but an interaction (p.18). So the logic of choice yields products that people can delineate and purchase as solutions; the logic of care sees such products as embedded in evolving practices that involve fine-tuning, tradeoffs, and continuing results. And about those results: in the logic of choice, if someone rejects a product, they are no longer considered part of the target market; in the logic of care, the caregiver keeps trying (p.22).

So that's the market version of the logic of choice. But there's also a civic version, that which casts patients as citizens able to “vote” on their care: “the relationship is moulded in the form of a contract” (p.30). But Mol critiques this analogy because a citizen can control, tame, or escape the body politic, but a patient can't control, tame, or escape her own body (except, I will add, in the colloquial sense that we “escape” our bodies during death, a figure of speech that may not translate from the Dutch) (p.31). Rather, Mol suggests “patientism,” an analog of feminism in which patients-living-with-disease can constitute a standard rather than being seen as diverging from a standard.

The logic of care, then, might cast patients as customers or as citizens. But in both variations, choice is seen as a matter of balancing values based on fact (p.42). Mol critiques that stance. For instance, suppose that a patient is trying to keep her blood sugar levels below 10 mmol/l. In the logic of choice, patients attempt to achieve that normative fact, keeping their levels around 10mmol/l and often feeling failure when they cannot. But “within the logic of care, identifying a suitable target value is not a condition for, but a part of, treatment. Instead of establishing it before you engage in action, you keep on searching for it while you act” (p.46). And “what follows is that for the logic of care gathering knowledge is not a matter of providing better maps of reality, but of crafting more bearable ways of living with, or in reality” (p.46).

Another difference is in how the two logics handle collectives. The logic of choice understands collectives as markets or as voting, both of which involve the aggregation of individual choices. But the logic of care starts with the collective, recognizing that we can't separate the patient from her or his collective – family, friends, other support systems, all of which have to conform a bit in order to make care work. The logic of choice involves value-laden judgments, but “In the logic of care, the crucial moral act is not making value judgments, but engaging in practical activities” (p.75).

As I said, I like Mol's work very much, and I really like how she plays with different frames or articulations here. Much of her work in this book has direct applications to rhetoric. At the same time, I think she sometimes assumes remarkably credulous consumers (p.28), weak-willed patients (p.48), and professionals whose self-evaluations amount to simple self-praise (p.87). Consequently, the contrast tends to be a bit overdrawn in places. Yet the book overall is solid and thought-provoking. Definitely pick it up.

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