Orders and Their Others: On the Constitution of Universalities in Medical Work

Marc Berg
Configurations, Volume 8, Number 1, Winter 2000, pp. 31-61 (Article)

Published by The Johns Hopkins University Press DOI: 10.1353/con.2000.0001

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http://muse.jhu.edu/journals/con/summary/v008/8.1berg.html

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Orders and Their Others: On the Constitution of Universalities in Medical Work

Marc Berg Erasmus University Rotterdam Stefan Timmermans Brandeis University

Attempts to formalize, standardize, and rationalize are ubiquitous in Western worlds. Work practices are made more efcient, professional practices are supposed to become more scientic, and technical practices should obey universal standards. The disorder of current practices, according to such discourses, should be replaced by scientically established, rational, and universal modes of working and understanding. Given a certain task, the procedures drawn upon and the knowledge and artifacts used should adhere to scientic criteria, so that the outcomes achieved are optimaland more predictable. These universal modes are found through diligent scientic reasoning, and their superiority is self-evidentbut for those who remain blinded by irrational or biased beliefs.1 Within the social studies of science and technology (STS), these discourses and processes have been questioned. Universality, actornetwork theorists have argued, is not a transcendent, a priori quality of a body of knowledge or a set of procedures. Rather, it is an acquired quality; it is the effect produced through binding heterogeneous elements together into a tightly coupled, widely extended network. Likewise, formality is an effect created by the rendering docile of a network, and by the concurrent production and channeling of a stream of standardized inscriptions that afford easy manipulation. In
1. For examples of such discourses in medicine, see D. M. Eddy, The Challenge, Journal of the American Medical Association 263 (1990): 287290; David L. Sackett and William M. C. Rosenberg, The Need for Evidence-Based Medicine, Journal of the Royal Society of Medicine 88 (1995): 620624.
Congurations, 2000, 8:3161 2000 by The Johns Hopkins University Press and the Society for Literature and Science.

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his elegant study on the creation of universality, Joseph OConnell discusses the history of electrical units.2 Laboratory scientists, U.S. war planes, and consumers buying new TVs do not simply plug into some pregiven, natural Universal called the Volt. Rather, the volt is a complex historical construct, whose maintenance has required and still requires legions of technicians, Acts of Congress, a Bureau of Standards, cooling devices, precisely designed portable batteries, and so forth. When the U.S. Navy supplied Kuwait with airplanes before the Iraqi invasion, it had to install standards laboratories there rst: Kuwait bought not only U.S. Navy airplanes, but the U.S. Navy volt as well. Following Bruno Latours programmatic analyses, OConnell demonstrates how the apparent universality of science is tribute to the power of a collective rendered stable by the pre-circulation of stable objects; creating universality is establishing the authority of a particular representative, circulating it, and assuring that comparisons are made to it.3 Other theoretical traditions within STS likewise question these rhetorics. Social-constructivist analyses, for example, also argue that the universality of technology or knowledge is an emergent property: to them, a fact or a technology becomes universal when the relevant social actors dening it share a common denition.4 Current work practices, according to all these analyses, should not be too easily labeled irrational and disordered: they only seem disordered, most STS researchers would argue, when idealized and impoverished universal models are imposed on them as a measuring stick. These arguments all combat the notion that the ubiquitous utilization of a procedure, a fact, or an artifact is self-explanatory; they undermine the view that universality is a quality inherent in the knowledge or the artifact. Yet in showing the constructed nature of universality, many actor-network theory (ANT) and social-constructivist analyses reproduce some crucial tropes that are part and parcel of the very story they are trying to erode. Universality is depicted as an effect, but then it is often granted some of the qualities that gure as a prioris in the received scientistic or technologically determinist tales.
2. Joseph OConnell, Metrology: The Creation of Universality by the Circulation of Particulars, Social Studies of Science 23 (1993): 129173. 3. Ibid., p. 165. See Bruno Latour, Aramis, or the Love of Technology (Cambridge, Mass.: Harvard University Press, 1996): G. Bowker, Science on the Run: Information Management and Industrial Geophysics at Schlumberger, 19201940 (Cambridge, Mass.: MIT Press, 1994). 4. Wiebe E. Bijker, Of Bicycles, Bakelites, and Bulbs: Towards a Theory of Sociotechnical Change (Cambridge, Mass.: MIT Press, 1995); H. M. Collins, Changing Order: Replication and Induction in Scientic Practice (London: Sage, 1985).

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In Latours classic Science in Action, the overall trope is the work and translations involved in the alignment of heterogeneous allies in an expanding network; in the classic studies of Trevor Pinch and Wiebe Bijker, closure is reached through aligning relevant social groups.5 Although these studies stress that closure is always temporary and that a network is never rendered fully docile, the creation of order is argued to depend on consensus, or on rendering equivalent and stabilizing that which was different and untamed. What remains uncontestedor is even conrmedin these studies, is that the production of universality follows a clear temporal pattern: disorder preexists and precedes the emergence of order. The phoenix of universality rises from the ashes of local chaos. In the structure of these accounts, the local is the generic, natural state that is subsequently transformed; it is the unquestioned base from which the analysis starts. In addition, these analyses reproduce the imagery that universality is singular. Whereas the local is plural by denition (there are many localities), the received view that universality does not have a plural is rarely explicitly questioned. In many early ANT studies, the victorious network-builder was a lone hero, a powerful spider in his web who allowed no other winners.6 And although the emphasis on interpretive exibility had introduced the possibility of varying endpoints of technological trajectories, studies mostly focused on cases where one solution overcame all other possible ones.7 Achieving universality, in these accounts, is the erasure of local varieties, the gradual grouping and transforming of what used to be dissimilar under the same category. There is nothing outside this unique yet all-encompassing space except that which has been erased or subsumed (Fig. 1).8
5. Bruno Latour, Science in Action (Cambridge: Cambridge University Press, 1987); Trevor J. Pinch and Wiebe E. Bijker, The Social Construction of Facts and Artefacts: Or How the Sociology of Science and the Sociology of Technology Might Benet Each Other, Social Studies of Science 14 (1984): 399441. 6. See, e.g., Michel Callon, The Sociology of an Actor-Network: The Case of the Electric Vehicle, in Mapping the Dynamics of Science and Technology, ed. Michel Callon, John Law, and Arie Rip (London: Macmillan, 1986), pp. 1934; Bruno Latour, Give Me a Laboratory and I Will Raise the World, in Science Observed, ed. Karin D. Knorr-Cetina and Michael Mulkay (Beverly Hills: Sage, 1983), pp. 141170. 7. See, e.g., the studies in W. E. Bijker, T. P. Hughes, and T. J. Pinch, eds., The Social Construction of Technological Systems: New Directions in the Sociology and History of Technology (Cambridge, Mass.: MIT Press, 1987). 8. For such critiques (often raised by those largely sympathetic to the theoretical enterprises scrutinized) see, e.g., Nick Lee and Steve Brown, Otherness and the ActorNetwork: The Undiscovered Continent, American Behavioral Scientist 37 (1994): 772790; Annemarie Mol and John Law, Regions, Networks and Fluids: Anaemia and

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Figure 1. The imagery of order and disorder in both standard views and many ANT and social-constructivist studies. The temporal axis can go either waya temporary order can dissolve and return to the disorder that was before.

For these studies as well, then, order is opposed to disorder; the stable is contrasted to the unstable; the formal to the informal; the universal to the local. Although the genealogy of the former terms is thoroughly rewritten, the tension and opposition between the two has been largely left unchanged. In recent years, however, several authors have started to problematize these similarities. Whether as a direct critique on the above-mentioned works or not, many studies have focused on the multiplicity that characterizes the products of technoscientic network-building whether discourses of rationality and objectivity, conceptions of the body, or scientic techniques.9 The feminist/technoscience
Social Topology, Social Studies of Science 24 (1994): 641671; John Law and John Hassard, eds., Actor Network Theory and After (Oxford: Blackwell, 1999); Mike Lynch and Kathleen Jordan, Instructed Actions in, of, and as Molecular Biology, Human Studies 18 (1995): 227244; Nicolas Dodier, Les hommes et les machines (Paris: Mtaili, 1995); Donna Haraway, A Game of Cats Cradle: Science Studies, Feminist Theory, Cultural Studies, Congurations 2 (1994): 5971; Leigh Star, Power, Technologies, and the Phenomenology of Conventions: On Being Allergic to Onions, in A Sociology of Monsters: Essays on Power, Technology and Domination, ed. John Law (London: Routledge, 1991), pp. 2656. 9. See, e.g., Mary Jacobus, Evelyn Fox Keller, and Sally Shuttleworth, eds., Body/Politics: Women and the Discourses of Science (New York: Routledge, 1990); Joseph Rouse, What

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studies of authors such as Donna Haraway and Leigh Star, for example, have put the political importance of investigating the nature of the technoscientic products at center stage.10 Likewise, authors like Karin Knorr-Cetina and Ian Hacking have emphasized the disunity found in scientic modes of practice and reasoning.11 Building upon these resources, we would like to push the analysis of the construction of universality/ies a bit further by focusing on two cases where the production of universality is at stake. We zoom in on two different technologies that are to rationalize the practice of medicine: Advanced Cardiac Life Support (ACLS) algorithms from the American Heart Association, and the mathematical techniques of decision analysis. The former are used to standardize and enhance the efciency of resuscitation efforts by which medical professionals are instructed to thwart off sudden death;12 the latter emerged from mathematical approaches to decision problems in conditions of uncertainty such as operations research and game theory.13 Translated for medical purposes, decision analysis attempts to calculate the action with the highest expected utility for a given condition. It can be drawn upon as a tool for decision making on individual cases, but it
Are Cultural Studies of Scientic Knowledge? Congurations 1 (1993): 122; Isabelle Baszanger, Deciphering Chronic Pain, Sociology of Health and Illness 14 (1992): 181215; Lorraine Daston and Peter Galison, The Image of Objectivity, Representations 40 (1992): 81129; Lisa M. Mitchell and Alberto Cambrosio, The Invisible Topography of Power: Electromagnetic Fields, Bodies, and the Environment, Social Studies of Science 27 (1997): 221273; Marc Berg and Annemarie Mol, eds., Differences in Medicine: Unraveling Practices, Techniques, and Bodies (Durham, N.C.: Duke University Press, 1998). 10. Donna J. Haraway, Simians, Cyborgs, and Women: The Reinvention of Nature (New York: Routledge, 1991); Susan Leigh Star, ed., Ecologies of Knowledge: Work and Politics in Science and Technology (New York: State University of New York Press, 1995). 11. Ian Hacking, Style for Historians and Philosophers, Studies in the History and Philosophy of Science 23 (1992): 120; Karin Knorr-Cetina, The Care of the Self and Blind Variation: The Disunity between Two Leading Sciences, in The Disunity of Science: Boundaries, Contexts, and Power, ed. Peter Galison and David J Stump (Stanford: Stanford University Press, 1996), pp. 287310. For a study in the medical domain that builds upon Hackings work, see J. Fujimura and D. Y. Chou, Dissent in Science: Styles of Scientic Practice and the Controversy over the Cause of AIDS, Social Science and Medicine 38 (1994): 10171036. 12. CPR-ECC, Standards for Cardiopulmonary Resuscitation and Emergency Cardiac Care, Journal of the American Medical Association 227 (1973): 836868. 13. For this history see, e.g., Paul N. Edwards, The Closed World: Computers and the Politics of Discourse in Cold War America (Cambridge, Mass.: MIT Press, 1996); Philip Mirowski, When Games Grow Deadly Serious: The Military Inuence on the Evolution of Game Theory, in Toward a History of Game Theory, ed. E. R. Weintraub (Durham, N.C.: Duke University Press, 1992), pp. 227255.

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is not widely used for these purposes; yet it is widely used as a technology to dene the proper treatment for categories of patientsfor health policy, for example, or in the construction of medical protocols.14 These technologies are both part of the efforts to rationalize medical work; they both attempt to render practices more scientic by invoking formal technologies and by erasing unwarranted local variations. We could tell both stories as attempts to replace disorder with order, to create a new network, to discipline medical work in and through introducing formal technologies. Yet if we look inside these networks, we shall argue, we encounter two different as universalities. Although we remain within the rather circumscribed domain of technologies that are meant to rationalize medical work, even here we do not witness the production of a singular order, but of two, only partially connecting orders: an order characterized by a statistical logic, and an order based on the enforcement of a chain of prescribed actions, linked through symbolic rules or instructions. In addition, these orders do not emerge out of (and thereby replace) a preexisting disorder. Rather, with the production of an order, a corresponding disorder comes into being. To use Annemarie Mols words, wildness does not precede order, but creating order produces its wildness.15 Rather than an opposition, then, there is an intimate connection between the two. Moreover, the intimacy of this connection does not stop here: not only does an order perform its own disorderit also always contains it. This is the case whether seen
14. Marc Berg, Rationalizing Medical Work: Decision Support Techniques and Medical Practices (Cambridge, Mass.: MIT Press, 1997); M. Ashmore, M. Mulkay, and T. Pinch, Health and Efciency: A Sociology of Health Economics (Milton Keynes: Open University Press, 1989). 15. Personal communication. The anonymous referees have pointed out that, as a philosophical theme, this claim is not original: Kuhns anomalies, for one, were disorder only in the light of a specic paradigm. Likewise, Bruno Latour would argue that this claim lies at the philosophical roots of his theorizing: Order, he says in his Irreductions, is extracted not from disorder but from orders (Bruno Latour, The Pasteurization of France [Cambridge, Mass.: Harvard University Press, 1988], p. 161). The argument, however, has not been very prominent in recent empirical STS work. Resetting the classical debates on art versus science, for example, some studies have indeed argued that the former should not be seen as a primitive situation that is prior to, and threatened by, the latter: see, e.g., Alberto Cambrosio and Peter Keating, Going Monoclonal: Art, Science, and Magic in the Day-to-Day Use of Hybridoma Technology, Social Problems 35 (1988): 244260; Warwick Anderson, The Reasoning of the Strongest: The Polemics of Skill and Science in Medical Diagnosis, Social Studies of Science 22 (1992): 653684. Our claim, however, is different in that we focus on how what counts as wild is coproduced with the emergence of the order, and how different sciences thus invoke different coexisting arts.

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in historical perspective (the genealogy of the specic order in question) or with an ethnographic eye (the real-time performance of the order). The order and its disorder, we argue, are engaged in a spiraling relationshipthey need and embody each other. These relationships can only be seen as paradoxical from a view that labels them as opposite. We will show how a statistical order despises ungrounded clinical reasoning yet depends on it, how lesser rules can lead to more stable performance, and how more statistical rigor can yield statistically less worthy outcomes. The orders and their disorders are, to use Michel Serress term, each others parasites.16 What is true for the practices is also true for the accounts of these practices. Attempts to impose general understandings of work practices produce and contain their Other just as do attempts to impose a general order upon work practices. Actor-network theory was supposedly an empty theory, capable of describing all potential orders and their othersyet not disappearing into a postmodern display of incommensurable voices, since it provided the frames of reference (the actor-network) that would permit traveling between the stories.17 Yet its universality was not the neutral realm it promised to be. As feminist and other critiques have argued, it tended to focus on the heroic exertions of the central actor, and it embodied a stereotypical, engineering logic (building wholes with heterogeneous elements, controlling the periphery from the center). By speaking of trials of strength, forces, and strategies, it reproduced exploitative and warlike metaphors of scientic activity that feminist authors have been criticizing for yearsthus producing yet another Sacred Image of the Same.18 As Nick Lee and Steve Brown argued, actor-network theory is a totalizing strategy; there is no way of circumventing the formulaic circle of expansion, domination, and collapse.19 Seeing how actor-network theory produced its own Other, its theory can be made even thinner. A great deal of our vocabulary, Latour recently stated, has contaminated our ability to let the actors build their own space.20 The network can be depicted as a specic type of topology,

16. Michel Serres, Rome: The Book of Foundations (Stanford: Stanford University Press, 1991). 17. B. Latour, A Relativistic Account of Einsteins Relativity, Social Studies of Science 18 (1988): 344. 18. Haraway, Game of Cats Cradle (above, n. 8), p. 70; Star, Power (above, n. 8). 19. Lee and Brown, Otherness (above, n. 8), p. 781. 20. Bruno Latour, On Recalling ANT, in Law and Hassard, Actor Network Theory and After (above, n. 8), pp. 1525, p. 20.

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one spatial form among otherssuch as uids or trails.21 A network is the kind of spatiality that might come into being together with stabilized scientic facts and artifacts. Fluids or trails are less clearly demarcated, less predictable, decentered spatial forms, in which elements can stick together more looselyyet, when taken as a whole, rather robustly. The networks order is more exclusionary, more expansionist, and tends toward uniformity; the uids or trails orders are more about partial connections and multiple memberships.22 These spatialities, then, can be said to be themselves emergent properties. They are no longer the a priori conceptual categories that the researcher brings to her study: they are the topologies that are performed in the practices studied. Yet for the specic ordering activities we are investigating here, the network remains an appropriate concept. Tying together practices through different spaces and time, creating equivalencies through disciplining disparate entities: we are indeed here studying topologies not unlike the networks that were the archetypal examples for the classic actor-network studies. Actor-network theory, however, is transformed here as well. These networks that are emerging should be seen to contain their Other rather than to dissolve it. Multiplicity, instability, marginality, multicenterednessas several authors are starting to point out, the heterogeneous network acquires its existence partly through incorporating instability and multiplicity in its very core.23

Multiple Universalities
First formulated in the early eighties, ACLS algorithms are designed to be used by trained and certied professional rescue personnel as a more advanced kind of CPR (cardiopulmonary resuscitation). These protocols spell out the assessment and A-B-C-D sequence of lifesaving: A stands for clearing the Airway, B for
21. Mol and Law, Regions, Networks and Fluids (above, n. 8); Adrian Cussins, Norms, Networks and Trails, paper presented at the conference After ANT: Second Annual Conference CSTT, Keele, July 1997. 22. These terms have been put into circulation through the writings of Marilyn Strathern (Partial Connections [Lanham, Md.: Rowman and Littleeld, 1991]) and Donna Haraway (Simians, Cyborgs, and Women [above, n. 10]). 23. Vicky Singleton and Mike Michael, Actor-Networks and Ambivalence: General Practitioners in the UK Cervical Screening Programme, Social Studies of Science 23 (1993); 227264; Stefan Timmermans and Marc Berg, Standardization in Action: Achieving Universalism and Localization in Medical Protocols, ibid., 27 (1997): 273305. Leigh Stars notion of boundary object could be argued to contain the same message: Susan Leigh Star and James R. Griesemer, Institutional Ecology, Translations, and Boundary Objects: Amateurs and Professionals in Berkeleys Museum of Vertebrate Zoology, 190739, ibid., 19 (1989): 387420.

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restoring Breathing functions, C for reestablishing the blood Circulation, and D for Debrillation and Drug therapy. Each of those phases consists in turn of a number of actions that need to be performed consecutively to be successful. We read the order inscribed in a rationalizing tool by deciphering its script: 24 what ideal practice does the tool presuppose, what notions of optimal medical work do its authors advance in their writings? The protocols prescribe a series of conditional actions: in situation X, do A. These instructions, in addition, should be followed in a prespecied sequence, step-by-step. The strict following of the instructions will ensure that the end-situation of step 1 fullls the conditions of step 2, that the end-situation of that step fullls the conditions of step 3, and so forth. So, the rescuer should perform the head-tilt/chin-lift maneuver before looking, listening, and/or feeling for breathing: only when the airway is opened in this way (i.e., only when the victim is mechanically able to breathe) does it make any sense to see whether the victim breathes. The protocol might branch: when certain conditions in the instructions are fullled, the protocol might take one path; if the conditions are not fullled, it might take another. The Universal Algorithm for Adults branches off into different directions and different protocols depending, in its rst steps, on the occurrence of vital signs, and later also on other diagnostic information. The distributed and socio-material performance of this specic rationality is well captured by Mark Seltzers term logistics, which merges the logic with the heterogeneous infrastructure to which it is tied.25 Through the nationwide teaching of CPR, the standardized examinations for rst-aid providers, the production of CPR manikins with recording equipment, regional 911 telephone networks, and ambulance systems, the ideal-typical rationality inscribed in the tool inscribes itself upon all American resuscitation events.26 This network serves to ensure a uniform execution of the resuscitation procedure regardless of local context. Ideally, an eighteen-year-old member of the Coast Guard in San Diego, California, who encounters a drowning, and a nurse with twenty-ve years of clinical experience who notices the vanishing shallow breathing of a newborn in
24. Madeleine Akrich, The De-scription of Technical Objects, in Shaping Technology Building Society: Studies in Sociotechnical Change, ed. Wiebe E. Bijker and John Law (Cambridge, Mass.: MIT Press, 1992), pp. 205224. 25. Mark Seltzer, Bodies and Machines (London: Routledge, 1992). 26. Stefan Timmermans, Sudden Death and the Myth of CPR (Philadelphia: Temple University Press, 1999).

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the neonatal intensive care unit of Massachusetts General Hospital, will react in a similarly ordered way. With the protocol as yardstick, the two events can be compared, evaluated, tallied, and used to calculate the overall survival ratios of resuscitative effortsespecially now that the so-called Utstein guidelines prescribe steps for the uniform reporting of data on resuscitation attempts.27 Creating order, here, is the production of a standardized chain of actions as a response to a circumscribed situation; a rationalized practice is a practice where such uniformity is prevalentand measurable. This is the order argued for by the critical epidemiologist Alvan Feinstein, who has claimed for decades that the standardization of procedures is the crux of a rational medicine. To improve clinical decision making, he argued in 1977,
[d]octors would need to develop better methods of performing and standardizing clinical examination; better procedures of identifying the many important entities that are now ignored when clinical data are collected; better systems of taxonomy to classify and code the additional forms of data; and better dissections of the judgement with which the data are analyzed and interpreted.28

The protocols would help bring this improvementthrough them, resuscitation practice can achieve the reproducibility and standardization required for science.29 At rst sight, a similar order is inscribed in decision analysis. Put briey, a decision analysis starts with listing the possible individual outcomes of a given intervention, and assigning utilities and probabilities to them. The utilities stand for the value of a given outcome for the patient, expressed as a number. Multiplying the utilities and probabilities, and adding these per treatment option, yields the expected utility for that option. The option that yields the highest total expected utility is the action of choice (see Fig. 2).30
27. R. O. Cummins et al., Recommended Guidelines for Uniform Reporting of Data from Out-of-Hospital Cardiac Arrest: The Utstein Style, Circulation 84 (1991): 960973. 28. Alvan R. Feinstein, Clinical Biostatistics XXXIX. The Haze of Bayes, the Aerial Palaces of Decision Analysis, and the Computerized Ouija Board, Clinical Pharmacology and Therapeutics 21 (1977): 482496, p. 482. 29. A. R. Feinstein, An Analysis of Diagnostic Reasoning. III. The Construction of Clinical Algorithms, Yale Journal of Biology and Medicine 47 (1974): 532, p. 6. 30. There are many variations on this theme. Cost-efciency analysis, where costs are compared rather than utilities, is a potent actor in current health policy domains. Sometimes, benets are included in the form of QALYs (Quality Adjusted Life Years); see, e.g., Ashmore, Mulkay, and Pinch, Health and Efciency (above, n. 14). In the case of individualized clinical decision analysis, the utilities can be derived from the in-

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Figure 2. A simple decision tree for throat infection. A square node is a decision point; circular nodes indicate chance occurrences. The decision analyzed is to treat or not to treat. Possible outcomes are listed, and each has a probability assigned to it (.9, .05, and .05 for the upper branch) and a value, between 0 and 1, stating its utility (1, .3, and .8 for the upper branch: an allergic reaction, which might be fatal, is worse than an infection, which is usually self-limiting but might lead to complications such as peritonsillar abscesses). The net score of treat is (.9 1) + (.05 .3) + (.05 .8) = 0.955, and the net score of do not treat is (.5 1) + (.5 .8) = 0.9. Since the expected maximal value of treat is higher than that of do not treat, the physiciangiven this situation, these probabilities, and these utilitiesshould treat.

Again, uniformity and standardization are key words in the order that this technique embodies: the tool attempts to ensure that similar patients (i.e., patients presenting with a similar list of symptoms and complaints) are judged in similar wayswhatever the specics of the clinic, the experience of the responsible physician, and so forth. The results are comparable, evaluable, and can be used to generate further statistics such as efciency ratings, more rened costbenet analyses, and so forth. But the order of the resuscitation protocol only partially overlaps with the statistical logistics of decision analysis. The latter technique, rst of all, does not attempt to standardize a sequence of actions: it attempts to enhance the quality of decisions made. Decision analysis wants to support the physician where he or she is weakest: in drawing the proper inferences from complex sets of dataor, in other words, in deciding upon the optimal medical action to take. Rationalizing medical work, here, is ensuring that the optimal path
dividual, thus ensuring a personalized approach. (Parts of this section are derived from Berg, Rationalizing Medical Work [above, n. 14].)

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of action is taken given a certain situation; it is about making the right choice. The statistical logistics is geared toward single-moment interventions: it renders decisions uniform, but is not primarily interested in the processes leading to and from those decisions. In the words of one of its founders, the idea is to optimally look before you leap, to decide now, once and for allrather than to cross that bridge when you come to it (i.e., to make decisions in the course of action).31 A second major difference is that the latter universality is grounded in statistical inference. Optimal decisions are those decisions that are made through an exact, quantitative weighing of the evidence. When one knows certain basic facts (such as the probabilities and utilities of possible outcomes), decision making becomes a matter of scientic calculation. Fill in the appropriate formulae, and you will be given the treatment option with the maximal expected utility. The ACLS protocols logistics, on the other hand, are not primarily concerned with the purity of the reasoning that links its steps. Whereas the statistical logistics emphasizes the importance of the objectivity of calculation for each decision, the links between individual steps in the protocol are not reasoned for in a singular voice. The reasoning is not primary: in the current protocol, the steps are simply listed in that order, as authority to accept. The underlying reasoning could be statisticalstatistically sound experimental designs have proved that ventilating 2 times at 11.5 sec/inspiration is indeed the optimal intervention in that specic situation.32 Yet other steps are based on nonquantitative, pathophysiological or behavioral reasonings: the two slow breathings may lack statistical grounding or precision (how slow? why two?), but they are selfevident from a pathophysiological viewpoint.33 And the ratio 15 compressions per 10 seconds, and the 4 cycles of 15 compressions and 2 ventilations (which add up to 1 minute) that are found in all basic CPR protocols are designed to facilitate recall rather than to adhere to statistically proven optima. Likewise, in the ACLS protocol it is more important to rst call and later check for an open airway than to rst start CPR and then call fast. The reason for this seem31. L. J. Savage, The Foundations of Statistics, 2d rev. ed. (New York: Dover, 1972). See also Eddy, Challenge (above, n. 1); M. C. Weinstein et al., Clinical Decision Analysis (Philadelphia: Saunders, 1980). 32. P. Safar, Closed Chest Cardiac Massage, Anesthesia and Analgesia 40 (1961): 609613. 33. See, e.g., Feinstein, Clinical Biostatistics (above, n. 28).

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ingly odd reversal of priorities is again behavioral: studies have shown that when rst-responders were instructed to rst start CPR and then call later, they would spend as long as four or ve minutes assessing the patient and trying out CPR before dialing 911, and this closed the six-to-eight-minute window of opportunity to reverse the dying process too much for subsequent interventions to be successful.34 This amalgam of logicsbehavioral, statistical, pathophysiologicaldoes not make the protocols order less rational. Rather, the rationality and universality attempted by the protocol are different from those of the statistical logistics. It carves out a different ideal world: one that is based on and optimizes the inherent logic of professional health-care work. It is more pragmatic; it does not want to adhere to the unrealistic precision of the statistical logic; and it emphasizes that it has rm roots in the nitty-gritty and heterogeneity of the reality of emergency medical systems.35 Logistics are not governed by epistemology and ontologythey are the more basic categories, performing their own epistemology and ontology, as the worlds in Latours Irreductions.36 The logistics associated with the protocol and with clinical decision analysis have different notions of what medical work is, of what the problems of medical practice are, and of how doctors know and decide.37 They also embed different ethics. By emphasizing the importance of explicit and consistent criteria as a starting point, they both subscribe to a rule-based ethics rather than one based on notions of solidarity, care, or tragedy.38 Yet the statistical logistics, for one, embed a utilitarian ethics: they focused on outcomes, and (when applied to categories of patients) they will tend to maximize the utility on a group
34. See W. H. Montgomery et al., Citizen Response to Cardiopulmonary Emergencies, Annals of Emergency Medicine 22 (1993): 428435. 35. Feinstein, Clinical Biostatistics XXXIX (above, n. 28); J. A. Rizzo, Physician Uncertainty and the Art of Persuasion, Social Science and Medicine 37 (1993): 14511459. Herbert A. Simon, critiquing the impossible assumptions of decision analysis, argued that it is a beautiful object deserving a prominent place in Platos heaven of ideas (Alternative Visions of Rationality, in Judgment and Decision Making, ed. H. R. Arkes and K. R. Hammond [Cambridge: Cambridge University Press, 1986], pp. 97113, p. 100). Simons emphasis on satisfying ts in with the pragmatism of the protocols logic, and can also be found in that logics half-sister, Articial Intelligences Expert System; on these interrelations, see Berg, Rationalizing Medical Work (above, n. 14). 36. Latour, Pasteurization of France (above, n. 15). 37. Berg, Rationalizing Medical Work. 38. See Martha Nussbaum, Loves Knowledge: Essays on Philosophy and Literature (New York: Oxford University Press, 1991).

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level. This may imply compromising the needs of certain individuals: not intervening in certain instances so as to save resources for more effective interventions on other individuals, for example, or intervening on a large number of healthy persons (including the risk that comes with that) so as to prevent bad outcomes for a few of these.39 This utilitarian ethics is very different from that of the ACLS and CPR protocols: here, no questions as to the utility of performing a resuscitation are asked, and probability gures do not matter. Even when the chances of survival are practically zero, and even when a prolonged resuscitation effort may turn out to be very expensive, the prompt and unconditional execution of the procedure remains a basic tenet of this protocol. A decision to resuscitate based on statistical-probability reasoning of the survival ratios of particular groups of patients is anathema to the ACLS logistics, which stresses our moral duty in the light of the a priori, intrinsic value of each and every human life.40 We can extend the list, and spiral into our own vocabularies: the logistics also perform their own sociologies.41 As above, they make true categories that (sociological, ethical, epistemological) theorists had seen as descriptive, analytical universals. The statistical order understands human action as the outcome of economically rational calculations. Humans will choose that which maximizes their utility, and will act accordinglyunless, of course, they are biased by secondary factors. They are Machiavellian Subjects, who (if left to their own devices) will construe networks in which the goods they desire (including health-care provisions) will be juxtaposed to their benet. The protocols subjects are also rational actors: individuals who have good reasons for their acts. Yet they are more pragmatic, valuing the end over the means, and they abidelike functionalist actorsby mnemonics and norms. Unavoidably dipping into these logistics, we feel sympathy for the ones pragmatismand uneasy resonances with the others self-aggrandizing logic. Yet in depicting these logistics, we ourselves clearly also stand next to them, potentially contesting their validity just as they may challenge each other.

The Orders Disorders

In an excellent essay, Philip Agre discusses the discourse of formalization, which constructs itself as technical, formal, precise, accredited, and appropriable while constructing its Other as ordinary,
39. A. S. Brett, Hidden Ethical Issues in Clinical Decision Analysis, New England Journal of Medicine 305 (1981): 11501152; D. M. Eddy, The Individual vs Society: Is There a Conict? Journal of the American Medical Association 265 (1991): 14461450. 40. Timmermans, Sudden Death and the Myth of CPR (above, n. 26). 41. Latour, Aramis (above, n. 3).

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informal, vague, unaccredited, and unregulated. The technical marks itself as privileged in relation to the ordinary, and moreover makes the ordinary the object of a colonial project of reform; yet, he argues, these opposed terms are two sides of the same coin, joined in a relationship that cannot be either stabilized or eliminated. What the social project of formalization produces is this coin itself.42 The informal, in other words, does not precede the formal; it only comes into being with the formal, as a necessary and unerasable parasite. [The informal] is not the discourse of ordinary peopleit is, rather, the shadow side of technical discourse itself.43 In a similar way, the two orders we have described produce the very disorders they attempt to eradicate. They identify the enemy that they seek to conqueryet this identication process is not a selection of a pregiven problem, but a process wherein the specic problem is produced. With the statistical logistics, disorder emerges as the absence of quantitative links, of rigorous calculation, of impure reasoning. The statistical logistics is itself the very yardstick against which this disorder can emerge: it projects its ideal-type onto medicine, and then attempts to eradicate the shadows thereby cast. Within this logistics (its experimental set-ups, its ideal-typed performance criteria embedded in the tools, the format of its training programs), physicians emerge as poorly calibrated decision makers. What should be fought are informal, nonquantitative interpretations and ambiguous language. What should be mistrusted are criteria and guidelines that remain implicit, hidden, and can thus easily be inconsistent, illogical, nonreproducible, nongeneral, and noncomparable.44 What becomes a sin is not being optimally efcientthat is, not being focused primarily on maximizing the utility of the outcomes of ones actions. These are the wrongs that decision analysis sets out to remedy. Yet all these vices are simply the inverse of the virtues of the statistical logistics: it provides the model
42. Philip E. Agre, Formalization as a Social Project, Quarterly Newsletter of the Laboratory of Comparative Human Cognition 14 (1992): 2527. 43. Marc Berg, Of Forms, Containers and the Electronic Medical Record: Some Tools for a Sociology of the Formal, Science, Technology and Human Values 22 (1997): 403433. Quotation from Agre, ibid., p. 27. 44. R. D. Cebul, Decision Making Research at the Interface between Descriptive and Prescriptive Studies, Medical Decision Making 8 (1988): 231232; W. B. Schwartz, H. J. Wolfe, and S. G. Pauker, Pathology and Probabilities: A New Approach to Interpreting and Reporting Biopsies, New England Journal of Medicine 305 (1981): 917923; J. P. Kassirer et al., Decision Analysis: A Progress Report, Annals of Internal Medicine 106 (1987): 275291; D. M. Eddy, Anatomy of a Decision, Journal of the American Medical Association 263 (1990): 441443.

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against which practices can be judged to be suboptimal. It outlaws its enemyyet this enemy is in a fundamental way internal to the attempt to outlaw it. In a logistics that emphasizes uniformity through a chain of conditional actions, disorder is the negation of any of these core terms: nonuniformity, perturbing the prescribed sequence, disobeying the instructions. The Other of the protocols order is the variety that plagues medical work: the Tower of Babel of confusion due to the fact that an identical situation is treated, recorded, and evaluated differently by different health-care providers and medical researchers. What should be fought here is idiosyncrasy: action that does not follow the procedures deemed optimal by the most up-to-date scientic consensus.45 Here again, this logistics (the checklists and owcharts, the manikins, the CPR examination procedures) constitutes the yardstick that makes the very emergence of this specic disorder possible, perceptible. Disorder is made evident, for example, when the evaluators pen cannot simply move from top to bottom in scoring the rescuers performance because steps are missed or confounded. The very listing of instructions in a pre-scribed sequence on a form creates the possibility of disorder becoming immediately visible.46 Likewise, disorder appears whenever the standardized denitions that the Utstein researchers considered universally applicable for data reporting on CPR and ACLS seem for one reason or another not usable in a particular region. Yet again, the comparison of individual resuscitation practices becomes possible only when a nationwide organization of training in resuscitation, the diffusion of protocols, and the widespread utilization of the Utstein guidelines creates the structure within which all that is not performed in its liking shows as disorder. Partially, these disorders overlap: a lack of uniformity emerges as that-which-needs-to-be-tamed in both logistics. Both form examples in which the unexamined reliance on professional judgement appears as the problem with the coming of more structured support
45. Mickey Eisenberg et al., Survival Rates from Out-of-Hospital Cardiac Arrest: Recommendations for Uniform Denitions and Data to Report, Annals of Emergency Medicine 19 (1990): 12491259; J. J. Clinton, Improving Clinical Practice Journal of the American Medical Association 267 (1992): 26522653; D. E. Kanouse et al., Changing Medical Practice through Technology Assessment: An Evaluation of the NIH Consensus Development Program (Ann Arbor: Health Administration Press, 1989). 46. Jack Goody, The Domestication of the Savage Mind (New York: Cambridge University Press, 1977).

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and accountability for such judgement.47 Yet at certain intersections, what is order within the one becomes disorder within the other. For one, the protocols focus on preestablished sequences of basic procedures is suspect when seen from a statistical point of view. The latter, as said, is geared at evaluating decisions, and thus zooms in on single points in time. For this logistics, then, the xing of sequences of actionssuch as xing that the head-tilt maneuver has to be done after calling out Help, and that the victim has to be ventilated twice before assessing pulselessnessis often unduly simplistic in the face of the complexity of medical situations. Here, protocols bring in disorder: as a decision analyst points out, they constitute rigid recipes whose progression . . . is always the same, and thus can only stie intelligent action, not support or enhance it.48 In addition, the pragmatic reasoning underlying the CPR and ACLS guidelines is order for the protocol, but disorder for the statistical logistics. Guidelines steps and their links, in the words of a decision analyst, lack the solid mathematical foundation of decision analysis. They embody, at least in part, the disorder that the statistical logistics sets out to erase: they do not clearly separate facts from values, they do not clearly quantify their reasoning, and thus they lack objectivity.49 When scrutinized within a statistical logistics, the CPR and ACLS guidelines are indeed built upon disorder. The assertion that the ACLS protocols contribute in a statistically signicant way to lifesaving remains contested, even within the resuscitation research community. The only data available are regional survival rates on CPR attempts in general. But these are purestatisticaldisorder: they range from 1 to 33 percent. Moreover, any measured benet can be easily accounted for statistically by taking additional factors into account, such as differences in population. A lower survival rate in (for example) West Palm Beach than in Seattle does not have to be explained by the nonutilization of CPR or ACLS techniques: it might
47. M. J. Field and K. N. Lohr, eds., Clinical Practice Guidelines: Directions for a New Program (Washington, D.C.: National Academy Press, 1990), p. 21. 48. C. Sultan, M. Imbert, and G. Priolet, Decision-Making System (DMS) Applied to Hematology: Diagnosis of 180 Cases of Anemia Secondary to a Variety of Hematologic Disorders, Hematologic Pathology 2 (1988): 221228, p. 227; J. P. Kassirer and R. I. Kopelman, Diagnosis and Decisions by Algorithms, Hospital Practice 25 (1990): 2324, 27, 31. 49. Kassirer et al., Decision Analysis (above, n. 44); E. H. Shortliffe, Medical Informatics and Clinical Decision Making: The Science and the Pragmatics, Medical Decision Making 11 (1991): 214 (suppl.).

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be explained by the fact that the former, a retirement community, has a much older and sicker population than the latter.50 In the eighteenth century, the British Royal Humane Society went through a thirty-year period without articially stimulating the respiratory functions: the only treatment was to immerse drowning victims in warm baths. To the surprise of many, survival rates did not dip during this period, but even rose a little. Statistically speaking, less treatment seemed to save more lives. What would randomized trials show about the efcacyand possible iatrogenesisof CPR or ACLS? Yet the statistical order itself becomes disorder in the protocols logistics. Advocating the usage of protocols (algorithms, as he calls them), Feinstein argues that applying a statistical logic is simply much too rened and monolithic. Rationalizing instruments should be based on the demands of real work, he arguesit makes little sense to demand, instead, that reality adapt itself to t the model.51 Even though there might not be statistical proof, the utility of CPR or ACLS is obvious from a clinical point of view, many argue: in the light of a potentially saved life, the demand for denite, statistical evidence is simply mistaken.52 In addition, protocols can embody the reasons why step B follows step A. A protocol can delineate the pathophysiology that underlies a sequence of actions, or the morbid anatomic entities that are at stake in the choice of a therapy. Statistics, to the contrary, can only compute a numerical probability: a statistical logistics, with its clinically alien arrangement of statistical scores, ignores the scientic demand for diagnostic explanations of clinical evidence and it provides no pattern of logic for seeking scientic explanation.53 The pathophysiological explication that CPR restores circulation and
50. P. E. Pepe, N. S. Abramson, and C. G. Brown, ACLSDoes It Really Work? Annals of Emergency Medicine 23 (1994): 10371041; M. S. Eisenberg et al., Cardiac Arrest and Resuscitation: A Tale of 29 Cities, ibid., 19 (1990): 179186; Lance B. Becker, David W. Smith, and Karin V. Rhodes, Incidence of Cardiac Arrest: A Neglected Factor in Evaluating Survival Rates, ibid., 22 (1993): 8691. 51. Feinstein, Clinical Biostatistics (above, n. 28), p. 494. See also A. R. Feinstein, Clinical Judgment Revisited: The Distraction of Quantitative Models, Annals of Internal Medicine 120 (1994): 799805. 52. E.g., Richard O. Cummins, CPR and Ventricular Fibrillation: Lasts Longer, Ends Better, Annals of Emergency Medicine 25 (1995): 833836. 53. Feinstein, Analysis of Diagnostic Reasoning. III (above, n. 29); A. R. Feinstein, The Intellectual Crisis in Clinical Science: Medaled Models and Muddled Mettle, Perspectives in Biology and Medicine 30 (1987): 215230; Feinstein, Clinical Biostatistics (above, n. 28). In fact, this specic rebuttal is weakened by evidence that does not leave the protocols logistics. Physiological studies have shown repeatedly that the value of CPR to restore the vital functions is negligible: see, e.g., Pepe, Abramson, and Brown,

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ventilation makes precise statistical nit-picking superuous, in this view. Pressing the chest properly squeezes blood out of the heart, and upon releasing pressure the heart lls with blood again. How can restoring the hearts function not be benecial? Statistics can prove that a certain correlation existsbut it can not explain it, nor argue for or against a certain interpretation. Statistics is about numbers, formulae, and empty correlations, according to Feinstein while medicine (and the essence of Science and Rationality themselves) is about content. So far, we have scrutinized two different orders, each with its own disorder. We have argued for the plurality of the universal, and for the emergence of the local with its corresponding universality. We want to interrelate the double meanings of order that are at play in our discussions: we focus on logistics that attempt to order work practices in the sense of making them orderly, tidy, rational, and uniform across different sites. Yet we want to stress that this rst meaning of orderthe verbis always tied to its second meaning, the noun: every ordering produces a specic pattern, an arrangement, a disposition. As we argued in the introduction, the activity of ordering has been studied in depth by STS, and the differences between produced orders are also increasingly on the agenda. Given the prevalence of standardizing and rationalizing practices, and given the fact that much mainstream social theorizing remains stuck in outlining the limits and dangers of such practices,54 this is an important development. Elucidating the content of coexisting universalities is a needed step toward a more ne-grained analysis and judgment of such rationalizing processes. Investigating the different forms these processes can take opens up a much broader specter of possible worlds, in which there are many more axes than merely more or less formalized or rationalized. The logistics described here have close relatives inscribed in many different tools and discourses both within and outside medicine. The randomized, double-blind clinical trial, which has become the sine qua non of a rational therapeutics, is grounded upon the notion of statistical inference
ACLSDoes It Really Work? (above, n. 50). And indeed, with years of experience and only occasionally a survivor, many rescuers have very little faith in their life-saving abilities: see Timmermans, Sudden Death and the Myth of CPR (above, n. 26). 54. See, e.g., George Ritzer, The McDonaldization of Society: An Investigation into the Changing Character of Contemporary Social Life (Thousand Oaks, Calif.: Pine Forge, 1992). For a further analysis, see Marc Berg, The Politics of Technology: On Bringing Social Theory into Technological Design, Science, Technology and Human Values 23 (1998): 456490.

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whose dominance is being contested by Feinstein and others there as well.55 It has become the core of what is now called evidence-based medicine: thestatisticalideal that all medical procedures should bestatisticallyproven to be benecial.56 The statistical logistics as it gures within medicine can be traced back to developments in postwar psychology and in economics, for exampleand before that, to work on military and economic decision making in and before World War II.57 And medicine is but one of its instantiations: quantitative, probabilistic reasoning is a norm in many scientic and nonscientic domains.58 The protocols historical roots, on the other hand, lie in mundane tools such as recipes and lists,59 and in the search for symbolic means to align actions spread out over space and time. Its logistics recurs in the omnipresence of checklists: are all instruments and medications in place for the anesthesia to proceed smoothly, are all surgical instruments back in their trays after the operation, are all the measuring instruments and alarm signals in an airplanes cockpit working properly before takeoff, have all the required surfaces and objects been cleaned by the cleaning crew? The same logic can be said to recur in the widespread practice of prepackaging the materials required for certain procedures such as operations, wound-care, assemble-it-yourself furniture, and so forth. These packages could be conceptualized as nontextual protocols: they are a means of standardizing a series of actions through pre-scribing not only which materials to use, but thereby also in what order to use them, what technique to employ, what steps are important, and so forth.

The Disorders within the Orders

The hard fact is that problems are realistic only if they are complicated, in fact too complicated for us to handle without a good deal of formal probability theory.60

In one of Jules Vernes famous stories, three men and two dogs
55. A. R. Feinstein, Clinimetrics (New Haven: Yale University Press, 1987); Harry M. Marks, The Progress of Experiment: Science and Therapeutic Reform in the United States, 19001990 (Cambridge: Cambridge University Press, 1997). 56. Sackett and Rosenberg, Need for Evidence-Based Medicine (above, n. 1). 57. G. Gigerenzer and D. J. Murray, Cognition as Intuitive Statistics (Hillsdale, N.J.: Lawrence Erlbaum Associates, 1987); Steve J. Heims, John von Neumann and Norbert Wiener: From Mathematics to the Technologies of Life and Death (Cambridge, Mass.: MIT Press, 1980); Theodore M. Porter, Trust in Numbers: The Pursuit of Objectivity in Science and Public Life (Princeton: Princeton University Press, 1995). 58. Ian Hacking, The Taming of Chance (Cambridge: Cambridge University Press, 1990). 59. Goody, Domestication of the Savage Mind (above, n. 46). 60. Howard Raiffa, Decision Analysis: Introductory Lectures on Choices under Uncertainty (Reading, Mass.: Addison-Wesley, 1968), p. 6.

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travel to the Moon in a capsule, red from a gigantic canon. At one point, one of the dogs (Satellite) dies, and the crew decides to set the corpse overboard. The rationalities of science and technology, according to Michel Serress commentary on this tale, cannot accept impurities tainting it.61 With some additional, useless garbage, the dead dog is expelled from this steel symbol of progress. Somewhat later, one of the crew-members looks through the capsules porthole and sees some kind of at bag oating next to the capsule, accompanying it with the same speed. They realize it is the dead dog, who, as a dead object obeying all mechanical laws, travels with them as a true satellite. Reality returns in the rational, Serres comments; science is inevitably followed by its own anthropology. There is no generic locality upon which a similarly generic universality is built, we have argued: order does not arise from chaos. An emerging order produces its specic disorder. In this section, we want to push this argument one step further: Every order necessarily envelops the disorder it has brought into beinglike the dead dog accompanying the spaceship. It invariably contains its Otherboth in its history, and in its everyday operation. It does not know a pure state; even the ideal-typed logics in the writings of their advocates twist and swirl in the attempt to deal with the impossibility of their own purity. In part, this phenomenon has been brought to the fore by several studies of the construction of technology. Studying the history of specic technological artifacts, many authors have emphasized the broad ranges of actors/actants that come into play, the continuous negotiations between all these actors/actants, and the unpredictability of the technologys trajectory that is the outcome of these negotiations.62 Each technology, then, carries the contingency, the politics, and the contexts that shaped its emergence in its core. And studies of the ongoing work with technological artifacts have emphasized the never-ending need to tinker, to work around, to articulate loose ends.63 An established technology never functions according to the ideologies of efciency and tech61. Michel Serres, Lobus, le canondeuxime fondation, in idem, Statues (Paris: Franois Bourin, 1987). 62. Bijker and Law, Shaping Technology (above, n. 24); Latour, Aramis (above, n. 3). 63. Lucy Suchman, Plans and Situated Actions: The Problem of Human-Machine Communication (Cambridge: Cambridge University Press, 1987); Brian Wynne, Unruly Technology: Practical Rules, Impractical Discourses and Public Understanding, Social Studies of Science 18 (1988): 147167; Susan Leigh Star, The Sociology of the Invisible: The Primacy of Work in the Writings of Anselm Strauss, in Social Organization and Social Process: Essays in Honor of Anselm Strauss, ed. David R. Maines (Hawthorne: Aldine de Gruyter, 1991), pp. 265283.

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nological rationality: messy, real-time work is a prerequisite for any technology to persist. Yet we can be more specic. In looking at the history or the realtime functioning of a tool, we argue, we can demonstrate that the tools we describe here inevitably incorporate their own irrationality within them. They appear to survive only because they do not eradicate their Other. The logics order and its Other, then, are two sides of the coin in a double sense: not only does the one come into being only with the otherit also cannot survive without it. In the development of clinical decision analysis, for example, we can see how the specic disorder that simultaneously emerges gets inscribed into the very tool itself. To design a decision tree, we have seen, one needs to know the probability that a certain outcome will occur. For the extremely simple tree depicted in Figure 2, one needs to know what the chances are that an allergic reaction will occur if a throat infection is treated with antibiotics, what the chances are of a full recovery, and so forth. Sometimes such data are readily available: epidemiological data may exist, or databases may be at hand from which the required probabilities can be extracted. More often than not, however, these elementary data are simply not available: research has not been done, databases are nonexistent or of poor quality, or the required probabilities cannot be calculated from the data that are gathered. As a response to this problem, clinical decision analysis advocates the use of subjective probabilities, or disciplined personal opinion:64 the physician is asked what she or he thinks the probabilities are, and these probabilities are then used in the calculation. Now all advocates of clinical decision analysis agree that subjective probabilities are a second-best option; ideally, objective probabilities should be more readily available. The gathering and use of subjective probabilities is riddled with problems: physicians are not very good in estimating probabilities, and they tend not to completely separate utilities and probabilities. The use of these probabilities, then, tarnishes the ideal of objective inference. Yet, the advocates argue, when only subjective information is available, the formal method of decision analysis ensures at the very least that that information is optimally used.65 This latter claim, however, is disputed by critics who charge that it
64. R. D. Cebul, A Look at the Chief Complaints Revisited: Current Obstacles and Opportunities for Decision Analysis, Medical Decision Making 4 (1984): 271283; L. J. Savage, Diagnosis and the Bayesian Viewpoint, in Computer Diagnosis and Diagnostic Methods, ed. J. A. Jacquez (Springeld, Ill.: Charles C. Thomas, 1972), pp. 131138. 65. A. Tversky and D. Kahneman, Judgment under Uncertainty: Heuristics and Biases, Science 185 (1974): 11241131; Cebul, Decision Making Research (above, n. 44); Kassirer et al., Decision Analysis (above, n. 44).

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simply makes no sense to multiply subjective probabilities, or to add themthat these gures do not have the mathematical characteristics that objectively gathered probabilities have.66 Whatever the precise stance in this debate, the utilization of subjective probabilities was a step deemed necessary to make decision analysis feasibleyet it thereby incorporated the statistical logistics Other into its core. There are several other examples of this same phenomenon. The use of the decision tree itself, for example, is seen as problematic by many decision analysts. The structure of the tree (the layout of the nodes and branches) strongly inuences the outcome of the decision analysis, yet this structure itself is not necessarily rigorous, its validity is not guaranteed, and it is saturated with nonquantitative content.67 Finally, the utilization of utilities, a prerequisite for the order that the statistical logic embodies, is even more contested than are the subjective probabilities. The utilities tend to uctuate over time, they change when a different method is used to elicit them, and their validity is impossible to establish. And how to incorporate other measures of benet such as costs? How to incorporate different, potentially conicting sets of such measures?68 Not surprisingly, many of its advocates argue that doing an actual analysis is more an art than a science. The epigraph to this section nicely sums it up: real problems are complex problems. It is exactly this complexity that calls for the utilization of a decision-aid such as decision analysisbut it is this very same complexity that makes the actual performance of such an analysis a perplexing undertaking. At each step, the analyst will have to make the subjective judgment whether the assumptions of the statistical tool match the specics of the situation. Already at the very rst step, for example, the statistical logic has to be complemented with judgments devoid of rigorous calculation: is this patient suitable for this specic tool? How do I translate a complex, real-world situation into a series of branches, cut-off points, and binary choices?69 In order for a logistics to exist, then, it has to incorporate its
66. P. J. H. Schoemaker, The Expected Utility Model: Its Variants, Purposes, Evidence and Limitations, Journal of Economic Literature 20 (1982): 529563. 67. W. B. Schwartz, Decision Analysis: A Look at the Chief Complaints, New England Journal of Medicine 300 (1979): 556559; Kassirer et al., Decision Analysis. 68. J. C. Hershey and J. Baron, Clinical Reasoning and Cognitive Processes, Medical Decision Making 7 (1987): 203211; J. G. Dolan, Can Decision Analysis Adequately Represent Clinical Problems? Journal of Clinical Epidemiology 43 (1990): 277284; D. M. Eddy, Cost-Effectiveness Analysis: Is It up to the Task? Journal of the American Medical Association 267 (1992): 33423348. 69. Raiffa, Decision Analysis (above, n. 60); Kassirer et al., Decision Analysis (above, n.

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Other. The content-rich structure of the decision tree, the notion of utilities, and the practicalities that arise during the trajectory of doing an actual analysis all show the recurrence of the vagueness, impurity, and subjectivity that decision analysis was to expel from the making of medical decisions.70 This phenomenon recurs wherever one focuses. In the attempts to construe a decision-aid built upon a statistical logic, for example, F. T. de Dombal and his team found that their tools accuracy and precision would sharply decrease whenever they attempted to increase its scope. The original version had dealt with acute abdominal pain complaints. In this domain, the tool appeared to impressively improve doctors decision-making abilities according to all the statistical criteria: increased diagnostic accuracy, optimized utilization of probabilistic evidence, and so forth. Yet each attempt to broaden the range of symptoms beyond those categorized as acute abdominal pain failed: when gynecological and urological symptoms were included, for example, the tools performance dropped below that of the clinicians original performances. Here again, then, the statistical order could maintain itself only by incorporating its disorder: subjective decision making remains the rule in most cases in order to allow the tool to excel in its own niche. The tools accuracy could be kept up only when it was not allowed to do its rationalizing work in most cases.71 These phenomena are, we argue, not temporary imperfections,
44); D. M. Eddy, Applying Cost-Effectiveness Analysis: The Inside Story, Journal of the American Medical Association 268 (1992): 25752582. 70. F. T. de Dombal, Back to the Future; or Forward to the Past? Gut 28 (1987): 373377. 71. I. D. Adams et al., Computer Aided Diagnosis of Acute Abdominal Pain: A Multicentre Study, British Medical Journal 293 (1986): 800804. A similar phenomenon occurred in the case of the CPR guidelines. The Utstein guidelines (meant to standardize and uniformize the data reporting of CPR attempts) are to be applied only when the collapse is caused by an underlying cardiac etiology: only by limiting to this subcategory the broad range of incidents and accidents that traditionally formed the site of resuscitative interventions were they able to make detailed instructions for mapping and following the CPR attempt. Yet cases of sudden infant death syndrome, drug overdose, suicide, drowning, hypoxia, exsanguination, cerebrovascular accidents, subarachnoid hemorrhage, and trauma are all noncardiac etiologies. Although the same lifesaving sequences will be performed on those victims, and although they were previously included in resuscitative efforts, they are excluded from survival rates with the Utstein guidelines. In addition, the unwitnessed cardiac arrests, the patients who do not show an initial cardiac rhythm of ventricular tachycardia (slow heartbeat) or ventricular brillation (in which the heart is no longer pumping), and the patients on whom bystanders did not initially perform CPR disappear in the grey area of unaccounted marginality. They are the disorderuncategorized, undescribed, unaccounted-forthat

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but a necessity. In order for a statistical logistics to enhance precise decision making, it has to incorporate imprecision; in order to be universal, it has to carefully select its locales. The parasite cannot be killed off slowly by gradually increasing the scope of the Order. Rather, an Order can thrive only when it nourishes its parasiteso that it can be nourished by it. The history of the CPR and ACLS protocols, in its turn, also shows how its own, specic disorder becomes part and parcel of the tool itself. For example, true to the protocols logistics, the representatives of the American Red Cross, the American Heart Association, and medical researchers wanted to make sure that CPR would be performed in the correct way when the general public rst started to learn the technique in 1973. If the quality of CPR was not optimal in training situations, it was argued, it would be much worse in the eld. They therefore designed a rigorous teaching program that included a lm, a lecture, a demonstration and training on a mannikin, and nally an extensive oral and practice test. The mannikins (called Resusci-Anne) were able to record compressions and rescue breathings on little strips of paper. During the training session the placement of the hand was detailed in ve steps, and potential rescuers were timed with stopwatches to make sure that they indeed compressed the chest for 0.5 seconds. During the last international conference on resuscitation techniques, the existing protocols and standing orders were revised again as they had been at every meeting. But in contrast with the previous revisions, this reformulation resulted in fewer guidelines and instructions as well as a shift from strictly testing lay-rescuers to (more informatively) evaluating them. The idea was to engage more people in life-saving measuresto get more people to learn CPR, and [to get] more people to start CPR.72 The existing CPR courses were considered too demanding: in an early pilot study, less than 50 percent of the two thousand potential rescuers were considered to be resuscitating adequately. In retrospect, Lance Becker points out that those stressful bystander CPR courses, requiring calliper-tested perfect 15 to 2 rhythm strips, with bruised hands, mouths and egos, [were] neither educationally nor physiologically sound.73 All these considerations led to a new set of protocols, which placed more emphasis on
makes possible the overall tightening of the protocols logistics that the Utstein guidelines propose. 72. Cummins, CPR and Ventricular Fibrillation (above, n. 52), p. 836. See also S. P. Winchell and P. Safar, Teaching and Testing Lay and Paramedical Personnel in Cardiopulmonary Resuscitation, Anesthesia and Analgesia (1966): 441449. 73. Becker, Smith, and Rhodes, Incidence of Cardiac Arrest (above, n. 50), p. 86.

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skills and focused less on rule following: there are fewer steps and fewer conditional instructions, and the remaining steps are less precisely circumscribed. By opting for less prescriptive precision, decreased measurability, and more discretionary leeway, the protocol explicitly incorporated its own Other. Now, with millions of Americans ready to engage in CPR, the technique has become a truly default intervention. Where in previous decades life-saving methods were used only by trained rescuers and only in some accidentsmostly drowningsCPR is now used whenever somebody collapses, a pulse or breathing cannot be found, and an ambulance is summoned. Paradoxically, then, the increased stability and reach of this network was not due to more (precise) instructions: the protocols logistics could thrive only by parasitically drawing upon its own disorder.74 This disorder also reenters the protocols logistics in an additional way: the looser criterialeading to increased utilizationdid not result in higher survival rates. In the majority of such cases lives cannot be saved, but the method is used nevertheless. The vast expansion of situations in which CPR or ACLS is being used has led to an equally vast increase in attempts that would have been considered futile before. Looser guidelines make it easier to engage in lifesaving but do not necessarily yield higher survival rates: in absolute numbers, more lives may be saved, but relatively speaking CPR is less successful in saving lives. Again, only by allowing a zone of borderline cases and attempts (which would have been ruled out or considered faulty in the previous protocol) to expand, only by allowing more of its own disorder into its logistics, has the CPR-ACLS network been able to extend itself. And we can see this necessity in the real-time functioning of the protocol as well. When a rescuer follows the steps of the protocol, the smooth execution of the instruction-sequence is often interrupted: ribs break, patients vomit, air enters the stomach instead of the lungs, the patient bleeds profusely, or there is no telephone available to call an ambulance. Or, and this is quite common, the protocol is followed for ve minutes, and nothing happens; ten minutes, half an hour, and nothing happens; longer, and still nothing happens. The protocols do not specify when it is appropriate to stop. In the words of Leigh Star, these contingencies require articulation work: work that gets things back on track in the face of the unex74. Vicky Singleton, Stabilizing Instabilities: The Laboratory in the UK Cervical Screening Program, in Differences in Medicine: Unraveling Practices, Techniques, and Bodies, ed. Marc Berg and Annemarie Mol (Durham, N.C.: Duke University Press, 1998), pp. 86104.

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pected and modies action to accommodate unanticipated contingencies.75 Without such tinkering activities, the protocol would inevitably stall; rough solutions have to be improvised, shortcuts have to be taken, and ad hoc decisions have to be made about when to stop resuscitating or when to keep going. It is, then, exactly the protocol logistics Otherad hoc, reactive, improvisatory actionthat allows the protocol logistics to exist. The Order/Disorder metaphor has allowed us to pursue a set of themes that recur in practices of rationalization, formalization, and standardization. This paper itself instantiates a totalizing move: according to our argument, there is no generalizing order that does not produce and contain its disorderand there is no disorder that is not a specic parasite of a specic order. While we discussed only two (albeit important) examples, the claim affects a much broader realm of self-reproducing dualities. The logistics we described here can be said to be part of the larger category called the formaland as we mentioned, the formal has its Other, the informal, which it simultaneously creates, rejects, and incorporates. We could address the logisticsagain partially related to those discussed hereassociated with the electronic medical record. This logistics emphasizes innite memory and universal accessibility, and redenes as disorder the incomplete and messy state of current record-keeping practices. But if we make some less direct connections, we are reminded of Bruno Latours recent argument that the modern, Western production of scientic facts is based upon the continuous mingling of quasi-objects and quasisubjectswhile it simultaneously denies this messy origin and claims a pure history of method and objective reality.76 And Marilyn Stratherns complex analysis of British/Western kinship can likewise be pointed at: a kinship system that declared itself naturaland thereby produced the counterpoint for the demonstration of the cultural beliefs underlying Other kinship patterns.77 Whether the order is produced by rationalizing tools or by industrious sociologists, whether it is embedded in conceptual
75. Star, Power (above, n. 8), p. 41. There is a dynamic interrelation between the orders and their disorders that we do not explore here. In their unremitting encounters, orders change, redene themselves. The incorporation of subjective probabilities in the statistical order, for example, can also be depicted as the emergence of a new order, in which this subjectivity was upgraded as the necessary ingredient of rational decision making. Thus, new orders emerge from the interplay between previous orders and their disordersand new disorders will come into being with them in a never-ending process. 76. Bruno Latour, We Have Never Been Modern (Cambridge, Mass.: Harvard University Press, 1993). 77. Marilyn Strathern, After Nature: English Kinship in the Late Twentieth Century (Cambridge: Cambridge University Press, 1992).

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dichotomies or in disciplinary feuds, the same principle would hold. This paper cannot but itself be a generalizing instant, an attempt to impose a master narrative, an exclusionary move. But maybe we do not need to reject such moves as the ultimate postmodern sin. There will always be some mimesis of, some collusion with, the narratives one wants to question. Yet when it is seen how every such move sustains that which undermines it, how the narrative has become narratives, and how it is in fact the master narrative that makes its Other possible, we might ease our fear for this form and might focus, again, on its contentto differentiate narratives, or to produce alternative ones; to act upon them, rather than retreat in an ironic drive for purity and innocence.78

Conclusions
Congruent with the powerful enlightenment notion of telos, and the Western cultural view that progress drives the metanarratives of science-technology-medicine, order is said to arise as a phoenix out of the ashes of disorder. In arguing that a new technology or fact comes into being with its application rather than as a solution to a pregiven problem, this modernist origin myth is partly denounced by scholars of science and technology. Science and technology studies have also been particularly apt at demonstrating how every order is but solidied disorder: how facts and technologies are the outcome of contingent negotiation processes. These products do not emerge from processes only to enter some preexisting modes of existence such as Truth or Technological Rationality. Rather, what emerges subsequently counts as truth or denes what it is to be efcient.79 Another trope of the modernist myth of universality is that this term cannot be plural. Building upon, among others, feminist and historical studies of technoscience, we have argued that qualifying the content of the emerging order allows us to demonstrate the multiplicity that reigns even among that which is labeled universal. Likewise, it then becomes possible to ascertain how in the history and everyday functioning of a specic logic its disorder gures. These arguments affect the position of those authors who have
78. Bruno Latour, in his reply to commentaries to his paper On Interobjectivity (Mind, Culture and Activity 3 [1996]: 228245), argues that no narrative can be the master of any reader, since there is no naive reader and of course, no writer mastering its own writing (p. 266). 79. Adele E. Clarke and Joan H. Fujimura, eds., The Right Tools for the Job: At Work in Twentieth-Century Life Sciences (Princeton, N.J.: Princeton University Press, 1992); Collins, Changing Order (above, n. 4).

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criticized standardization and/or formalization processes by pointing out that what appears as disorder from the rationalists perspective is, in fact, the fundamentalinformal, ad hoc, artlikeorder that keeps work practices going. The concept articulation work, for instance, is often used as a basic descriptor of human work, as a fundamental sociological category that can explain the practical limitations of formal rules and tools.80 Likewise, the art of skilled physicians is often said to be fundamental to medical work by medical professionals, and to be threatened by rigid protocols and deskilling decision-aids that impinge on it.81 In these accounts, the attribution of order and disorder is reversedbut their incommensurability and their disjoint origin stories are reproduced. Instead of the universal, the local here is reied as the yardstick against which our descriptions and judgments are measured. Although studies in the sociology of (technological) work have been of immense importance in demonstrating the workings of technologies in practice, and of human-machine interactions, we do not feel that ultimately this is an appropriate strategyneither analytically nor politically. We would like to rewrite such critiques; we would like to stress the multiplicity, the joint emergence, and the symbiotic relationships between the orders and their disorders. For us, the category articulation work is intimately connected to a logistics that revolves around explicating rules and implementing formal work-schemes; it cannot be positioned prior to it. Likewise, the art of medicine is the uid Other of theequally uidscience of medicine: tracing the history of these terms reveals a fascinating dance in always complementary yet shifting meanings.82 Neither articulation work nor art should be seen as the universal base of the pyramid, sustaining all that is built upon it. Articulation work is the parasitic Other upon which the protocols logistics and its siblings thrive; but this Other, as we argued earlier, emerges only with the Order it challenges and makes possible. The term, for instance, is less suited to describe the
80. See, e.g., E. Gerson and S. L. Star, Analyzing Due Process in the Workplace, ACM Transactions on Ofce Information Systems 4 (1986): 257270; Kjeld Schmidt and Liam Bannon, Taking CSCW Seriously: Supporting Articulation Work, Computer Supported Cooperative Work 1 (1992): 740; Graham Button, ed., Technology in Working Order: Studies of Work, Interaction, and Technology (London: Routledge, 1993). 81. F. J. Ingelnger, Algorithms, Anyone? New England Journal of Medicine 288 (1973): 847848; W. E. May, Consensus or Coercion, Journal of the American Medical Association 254 (1985): 1077. 82. Berg, Rationalizing Medical Work (above, n. 14); John Harley Warner, Science in Medicine, Osiris, 2d ser., 1 (1985): 3758. See also n. 15, above.

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statistical logistics Other: articulation work is an alternative depiction for a ow of actionnot for a form of reasoning.83 This does not imply that we cannot be critical vis--vis the generalizing orders. Quite the contrary: we feel that taking these emergent orders seriously is the most fruitful starting point for a critical position. Reifying the craft, art, or articulation work into its own Order cannot but blind us to the new worlds that are appearing through these standardization and rationalization efforts. Focusing on the multiplicity of the universal leads to a reevaluation of the cherished moral superiority of all things local that often recurs in such critiques. When the local is seen as always part and parcel of everything universal, the latter need no longer be perceived as a necessary (latent) threat. We can then stop unifying standardization and formalization, and scrutinize the politically relevant axes of difference that run through these categories. Preferring the protocols world over the statistical logistics, we are nevertheless critical about its often nave self-portrayal as a transparent carrier of scientically optimal knowledge, and about its equally nave, built-in dogmatism on the single best answer to a complex medical situation. Yet protocols can help explicate the criteria upon which medical decisions are madefor both health professionals and patients. In addition, well-designed protocols can actually create new responsibilities and opportunities for health-care workersenriching nurses work, and improving collaboration across disciplinary boundaries. It may very well be, then, that the most productive critical position is to be found in the creation of alternative universalities, formalizations, or modes of standardization, rather than in the defense of the local.

Acknowledgments
Marc Bergs research has been made possible through a grant from the Netherlands Organisation for Scientic Research (NWO). We would like to thank the anonymous referees as well as Ruth Ben83. One referee argued that, in fact, researchers who use the concept articulation work make the same arguments as we do, and that from Strauss on, people who have used this concept have been very clear that there is a dynamic tension between universality (order) and articulation work. The point here is not that we do not make similar arguments when we focus on the protocols logisticswe do. Also, it is indeed true that these authors have been excellent in pointing at the dynamic tension between universality and articulation work. We point, here, at the fact that articulation work is not a universal descriptor of human work, but a description specically tied to a critique of rules, standards, and other tools that have logistics similar to the protocol. Only once this specicity is seen does it become logically possible to start paying attention to the multiplicity present in the realm of the standard or the universal. For a more indepth analysis of this argument, see Berg, Politics of Technology (above, n. 54).

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schop, Emilie Gomart, and Annemarie Mol for their support and critiques. We also would like to thank Mark Elam and the participants in the Keele Conference Actor Network Theory and After, and the members of the Maastricht University Research Group Care, Technology and Culture, for their comments and discussion.