Review of Annemarie Mol, The Body Multiple: Ontology in Medical Practice, Duke University Press, Durham and London, 2002, 196 pages.

The book The Body Multiple, by the Dutch philosopher Annemarie Mol, is many things at once — something which should perhaps be expected considering its principal subject: the concept of multiplicity. To begin with, the book presents an ethnography of medical practice, in particular, of hospital practices concerned with a specific disease, atherosclerosis. As part of this ethnography, Mol further elaborates one of the central claims of science and technology studies (STS), that of the constructed nature of reality. Moreover, in a subtext spread out on the bottom of the pages of the book, Mol provides a diary-style account of her encounters with various traditions in sociology, philosophy and anthropology. This combination of ethnographic research, theoretical argumentation, and accounts of personal experience, is of course a well-established approach in STS, known from the work of Steve Woolgar, Bruno Latour and John Law, among others. But Mol also does something more. Elaborating on constructivist studies in STS, she develops a distinctly philosophical argument. More precisely, The Body Multiple transforms the ethnography of techno-science into a philosophical practice: ethnographic research of hospital practices here becomes an occasion to articulate an ontology — one which posits the multiplicity of reality. To appreciate this move, it is no doubt necessary to refer to the particularities of science and technology studies as it is practiced in the Netherlands. Here, unlike in many other places, STS has also found an institutional home in philosophy departments, a situation which Mol makes sense of by presenting her work under the label of “empirical philosophy.” To my knowledge, Mol is the first to present work of this particular kind in a monograph published in English.

Ethnography as philosophical practice

How does Mol bring about what we could call her philosophical turn in the ethnography of techno-science in this book? One answer is that Mol follows in the footsteps of the French philosopher Michel Foucault. Like him, she zooms in on socio-material practices performed in a specific institutional setting, i.e. the hospital. And like him, she approaches these practices as sites where subjects and objects acquire their shape and definition. An ethnography of medical practices dealing with the disease “atherosclerosis,” which Mol conducted in an academic hospital in a middle-sized town in the Netherlands, provides the main thread of the book. (Mol renames her ethnography a “praxiography,” as she finds that there is little “ethnicity” to be discovered in a Dutch hospital.) The fieldwork has yielded accounts of the various ways in which the disease atherosclerosis is “done” in various sites in the hospital: in the clinic, the pathology-lab, the operating theater, the epidemiological research center, etc. Mol describes how in each of these sites, atherosclerosis takes on a somewhat different appearance: in the clinic, the disease is performed as “walking pain,” whereas in the pathology department, atherosclerosis gets defined as a “thickening of the blood vessel wall.” In recounting the different ways in which the disease is articulated in different settings in the hospital, Mol arrives at the claim that the various medical practices relating to atherosclerosis each enact a different version of this object. That is, from her ethnographic account of the differing articulation of the disease, Mol derives the claim of the ontological multiplicity of the object, atherosclerosis. The disease is more than one, she posits.

Alongside her ethnographic account of the multiplicity of the disease “atherosclerosis,” Mol draws on social theory to conceptualize this multiplicity. In the subtext that runs along the bottom of the page across the book, she explains how her argument further elaborates constructivist approaches in STS and symbolic interactionist accounts of the performance of social identity. Her focus on the enactment of disease in medical practice, Mol points out, is informed by the commitment in STS to the social study of phenomena which are usually classified as belonging to “objective reality.” In line with this tradition, Mol points out, her ethnography zooms in on the objective category of “disease” and not the (inter-)subjective category of “illness.” Mol then goes on to criticize constructivist work in STS, and in particular, laboratory studies. She argues that this work was still complicit with the modern scientific understanding of reality. Laboratory studies, she argues, presented reality as something that is solid and durable, once scientific facts have become well-established. But, says Mol, “Matter isn’t as solid and durable as it sometimes appears.” (p. 42) Objects should rather be understood as having a fragile identity, one which, moreover, “may differ between sites” (p. 43). One can wonder whether laboratory studies really presented reality as something solid and durable. For example, didn’t Steve Woolgar and Bruno Latour argue in Laboratory Life that as soon as facts become consolidated, they become invisible, and no longer cause any noticeable “resistances” to human intervention? It seems to me that Mol rather wants to open up different sites for the study of the manufacture of reality, besides the laboratories of big science. Be this as it may, her critique of the concept of construction leads Mol to replace it with the more fluid notion of “performance,” developed by Erving Goffman. This concept for her has the desired connotation of malleability and fragility, she says. Thus, Mol comes to argue that the concept of the staging of social identity, may be applied to the realm of objects, too. In socio-material practices in the hospital, the argument then goes, not just subjects, but objects too, are performed, staged, or, as Mol prefers to put it, “enacted.”

By re-arranging the sociological concepts of the construction of reality and the performance of identity, Mol prepares the ground for her philosophical claim. If an objective entity like disease is approached as something which is enacted in socio-material practices, she argues, then the ontological multiplicity of this object comes into view. In different practices in the hospital, every time a slightly different version of the disease “atherosclerosis” is enacted. This difference, Mol points out, must not be understood in terms of a fragmentation or pluralist character of objects. Instead, the multiplicity of objects must be taken to mean that they “are more than one but less than many (p55).” Multiple objects, Mol posits, hang together in specific ways. In the middle chapters of the book, Mol elaborates this claim ethnographically. Here she describes how coherence between the different versions of the disease is brought about in the hospital. This is achieved in different ways: in some cases, differing versions of the object get aligned. For instance, two visualisation technologies - radiology and ultrasound - enact atherosclerosis differently. The former shows vessel lumen, the latter tells about blood velocity. They are made comparable in the establishment correlates between lumen loss and blood velocity. In other cases, the various versions of the object are not actively brought into agreement, but lead a distributed existence : the epidemiological and the surgical definition of atherosclerosis, for example, may differ, but since these different versions of the object do not come into contact in practice, this does not become a problem. The achievement of commensurability or the lack of necessity thereof, are themes which have received much attention in STS. But Mol presents them as a further elaboration of her claim of ontological multiplicity. She refers to the above practices of achieving coherence as “coordination work.” That actors in the hospitals engage in such coordination goes to show that the multiplicity of objects should not be understood as irreducible.

This notion of “coordination work” bears many similarities with the concept of “modes of ordering” put forward by the British sociologist John Law, with whom Mol has collaborated over many years. In his book Organizing Modernity, Law presents this concept as a way to understand “social order” as something which is performed, rather than given. In this light, Mol’s point of the coordination of different versions of an object in practice, can be taken as an “ontologization” of the question of social order. In fact, Mol’s larger philosophical project in The Body Multiple can be understood in this way: she turns sociological questions into ontological ones. As I mentioned already, Mol herself characterizes her approach in this book, as “empirical philosophy.” By this she means “a philosophical narrative” (p4), developed by “drawing on social scientific, and more notably, ethnographic methods of investigation” (p7). However, it seems to me that what makes Mol’s philosophical project stand out from others’, is not so much empiricism in general, but a very specific brand of it. Many philosophers, after all, have drawn on empirical studies in their work, from Karl Marx to the philosopher of the cognitive sciences Paul Churchland, etc. Mol’s project rather stands out because of an ethnographic mode of philosophizing, informed by social theory. Accordingly, her work would be better labeled as “ethnographic philosophy,” or “ontological sociology” if these terms were not so ugly. Fortunately, that the perfect label for Mol’s particular research practice is still to be found does not mean that we cannot evaluate her argument.

Nothing less than the nature of the real

Mol’s argument is certainly also meant as a contribution to the sociology and anthropology of medicine. However, I am not sufficiently familiar with these fields to appreciate its merits. But when it comes to its philosophical merits, what makes her argument stand out from others is that Mol extends her claim of the multiplicity of objects to the multiplicity of reality. On multiple occasions, she reaffirms that “reality is varied” (p.164). The preoccupation with the nature of the real distinguishes Mol’s argument from other philosophies which theorize multiplicity. By way of contrast, the philosopher Gilles Deleuzes inferred from the fact that the identity of entities is multiple, that the question “what is” should no longer be our principal concern. He proposes to shift attention from “being” to “becoming” (“devenir”). Bruno Latour, in his later work, concludes from the instability of objects in practice, that the question whether a given object counts as real, as opposed to illusory, is no longer the foundational question, as it had been for modern philosophy. This question, he points out, can only be answered when the process of the articulation of a given entity, in science and/or politics, has come to an end. Indeed, Mol’s persistence in wanting to determine the nature of the real, also after the realization of multiplicity, leads to an exceptional concept of reality.

One key feature of Mol’s concept of reality is that access to objective reality in her case becomes a distinctly ordinary event. For most modern philosophy, access to the real is rare and exceptional. It is said to require discovery or revelation, or at the very least, a strict adherence to method and/or reason. For Mol, on the other hand, access to the real has always already been established: “We do not master realities enacted out there, but we are involved in them” (p.179). One way to characterize Mol’s position is to say that she takes up the notion of “being in the world” as it has been developed by pragmatist and phenomenological thinkers during the 20th century. Philosophers like John Dewey and Merleau-Ponty criticized the modern preoccupation with the mind, and have argued that subjects are embodied, and as such should be understood as being always already embedded in the world. These thinkers rejected the understanding of the human subject as locked outside reality. However, since pragmatists and phenomenologists developed this argument to account for the human subject, the understanding of objective reality in principle remained untouched by it. But Mol extends their argument to include this reality. As she redefines objective reality as something which is enacted in practices, the embeddedness of subjects in the world does not just apply to experiential reality, but also to objective reality. A problem with Mol’s argument is that it reifies reality to a degree, something that did not trouble the phenomenologists and pragmatists since they were in the business of outlining the place of the subject in the world. Mol, on the other hand, reintroduces a grammar that says “reality is…” Even as she introduces us to a fluid world in which things are enacted differently in different practices, she makes reality appear as something with stable and fixed features - those of multiplicity and flexibility. This brings us to the normative project of Mol in The Body Multiple.

Ontological politics

Mol has a particularly concise answer to the question what difference it makes to appreciate the multiplicity of objects. She argues that if we acknowledge that objects are enacted in differing ways in different practices, we come to realize that each given enactment of an object, and configuration thereof, is relatively optional. That is, from the existence of many differing versions of a given object, Mol derives that alternative enactments of the object are possible: “to stress ontological multiplicity is to lay bare the permanent possibility of alternative configurations” (p.164). Interestingly, Mol does not take this possibility as an occasion to re-affirm that reality is subject to human choice. Instead, she emphasizes that it is in the enactments of objects in practice that it comes to be decided which world we live in. It is in socio-material practices, and not by way of a choice made by subjects standing outside of external reality, that the world comes into being. Mol captures this situation in the term “a politics of what”. This politics, she says, acknowledges that the question of the good in answered in the enactment of objects in practice. It is opposed to a politics of who, which zooms in on the question which actors make the decisions (and according to which procedure). The politics of what finds its point of departure in the fact that “the goals of medicine are not given.” What the good life is, when it comes to disease, can only become clear in medical practice. In making this argument, Mol presents the good life as an object of politics, and in doing so she subsumes ethics under politics. Philosophers may raise problems about this. According to the liberal tradition, for example, ethics must be kept outside of politics. There the good life is taken as something which we cannot and should not try to agree on. But more troubling is that even as Mol turns the good life into a subject of politics, she does say very much about what form it should take.

Mol herself is the first to point out that her account leaves this question open. However, that Mol admits to a lacuna in her account does not make it less of a lacuna. The lack of specificity of the political practice that Mol foregrounds, can be explained by the fact that Mol, advertently or in advertently, lets go of the idea of politics as a practice that actors engage in alongside day-to-day medical practices. In this respect, an inconsistency in Mol’s argument jumps in the eye, which is especially remarkable since most of her argument is so extraordinarily coherent. As we saw above, Mol introduces her “politics of what” by pointing our that the goals of medicine are “essentially contested.” (p. 175). However, in the preceding chapters Mol had precisely argued that controversies are extremely rare in the hospital. Because differing versions of a given object are distributed over different practices, they rarely come into contact with one and another. Accordingly, Mol then pointed out, there is little occasion for disagreement among these differing versions of the object to come to the fore. But this raises the question, why would the same not apply to “the goals of medical intervention”? Why do they not lead a distributed existence, but instead, must be considered as “essentially contested”? Mol does not point out a location for the contestation of the goals of medicine. One troubling question that arises in this respect is how much room Mol really leaves for the actors themselves to perform the ethics and/or politics of medicine.

Over the course of her account, Mol gives surprisingly little attention to the moral-political problems that actors may encounter in the hospital. For example, in Mol’s account there are no patients who suffer from being reduced to a mere object of the scientific gaze. Instead, Mol criticizes the idea that patients are subjected to such reductions. She argues that the body that appears as an object of medical intervention on the surgical table is simply one version of the subject called patient, which exists alongside the fully human figure that appears in the consultation in the outpatient clinic. For this reason, Mol argues, there is no need to speak of a reduction of the human subject to a mere body-to-cut-into - they are instead two different versions of “the patient.” However pertinent Mol’s critique of the concept of reduction, it does have the implication that the problem of the passive patient is here theorized away. Something similar occurs when it comes to the problem of the relative impotence of medical professionals with regard to the power of pharmaceutical industries in opening up and closing down avenues of research into new forms of treatment. When she discusses the “big economic push” behind research into drugs for atherosclerosis, and the threat it poses to current treatments, such as surgery and walking therapy, Mol does not register a potential political problem. Instead, she observes that one set of enactments of the disease will be replaced by “a quite different configuration” (p114). Mol’s account of the enactment of disease in situated practices, tends to deflate normative problems.

The conceptualization of medical practice undertaken by Mol in The Body Multiple has great merits. By foregrounding the enactment of disease in situated practices, Mol ontologizes the questions that are posed in the social sciences about the performance of illness, and more generally, about the maintenance of social order. Moreover, Mol develops the ethnography of techno-scientific practices into a full-fledged philosophical argument, that of the multiplicity of objects. And from her ontology, she derives a simple but solid normative claim; social-material practices of the enactment of objects are the locus of politics. Mol thus opens up the possibility to account of politics as an ontological practice. However, the persistence with which Mol affirms the multiplicity of reality in this book, makes it difficult for her to fully appreciate events that overflow this base-line multiplicity: practices of unification, and practices of the articulation of a lack (of agency, for example). At the same time, it is precisely Mol’s allegiance to situated medical practices that allows her to articulate an ontology of the multiplicity of objects. It is an impressive achievement.

Noortje Marres works at the University of Amsterdam.