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Cells and the (imaginary) patient: the multistable practitioner–technology–cell interface in the cytology laboratory

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Abstract

Modern health care is inextricably bound up with technologically mediated knowledge and practice. It is vital to investigate its use and role in different clinical contexts characterized, on one hand, by face to face practitioner and patient encounters (where technology may be conceptualised as hindering therapeutic relations) and, on the other hand, by practitioners’ encounter with bodily parts in laboratories (where conceiving of patients may be thought of as confounding objectivity). To contribute to the latter, I offer an ethnographic analysis of cytology laboratory practitioners’ work and microscopic assessment of normal and abnormal cells. First, I discuss the biomedical literature on cytology and the quest for a non-variational bodiless vision. Second, I discuss the concept of multistability, first developed by philosopher of technology Don Ihde, here used to analyse technologically mediated perception and how practitioners interact with technology. Combined with long term ethnographic fieldwork it enables access to, and analysis and articulation of the implicit multifaceted practitioner–technology–cell interface embedded in clinical practice and diagnostic processes. I will also address some implications of my analysis for clinical cytology.

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Notes

  1. Cf. Ten Have (1995) on ethical aspects on medical technologies, and Fairman (1998) and Sandelowski (2000) on nursing and technology.

  2. Dorland and Anderson (1993).

  3. Cf. Myers (2008) on embodiment in a scientific laboratory context.

  4. There are several types of cytology samples besides Pap smears, for example sputum, bladder washings and breast cytology.

  5. The cytological classifications used for the assessments are unstable and have undergone several revisions over time (Clarke and Casper 1996). Some laboratories use screening machines to sort out the normal cytology samples. To date there are no machines capable of assessing and classifying abnormal cytology. The classification system used in vaginal cytology, i.e. the Pap smears, was recommended by the Swedish Society for Pathology and the Swedish Society for Clinical Cytology and is described as a modification of the international ‘Bethesda System’ and responding to the Swedish context and the National Board of Health and Welfare’s (1998) call for a more uniform cytological nomenclature. For the Bethesda system, cf. Anonymous (1989, 1993).

  6. In most cases, an abnormal Pap smear neither exclude nor confirm health or disease, and women receiving abnormal Pap smear test results may become liminal personae; they are betwixt and between (Forss et al. 2004).

  7. Postphenomenology deviates from earlier (Husserlian) phenomenology in that the notion of consciousness is replaced by the notion of embodiment, and through the focus on material/technology mediated intentionality (Ihde 1990, 2010a, b).

  8. Ihde build on and expands Heidegger’s famous ‘tool analysis’ (Heidegger 1977, 2008) although he is also critical of Heidegger’s discussion on technology (Ihde 2010b).

  9. The concept intentionality is central to (Husserlian) phenomenology. Intentionality refers to the directedness of consciousness, in that consciousness is always about something. Intentionality thus links the subject and object: “The experienced stands always in relationship to an experiencing subject” (Karlsson 1995, 18).

  10. Technological mediation and moral aspects of technology is further elaborated in the work of Verbeek (2005, 2011).

  11. The fundamental role of hermeneutics in medicine is described, e.g. by Svenaeus (2001).

  12. Despite the call for analysing concrete cases, postphenomenologically oriented scholars rarely conduct empirical studies to explore (other people’s) technologically mediated practices in particular contexts, for example through qualitative interviews and/or ethnography.

  13. While ethnography enables an exploration of cytology laboratory practices in the context in which this occurs, I wanted to avoid representing too narrow a context (Maxwell 1996). The choice of laboratories was therefore based on pre-known variations hypothesized as important; (1) private ownership and county council run laboratories; (2) the size of the laboratories, and; (3) the number of cervical cytology samples handled. In addition, there are significant differences between various cytology laboratories in Sweden concerning the proportions of deviant samples, the number of dysplasias found, and the proportions of samples that cannot be assessed (National Board of Health and Welfare 1998, 42). The two chosen laboratories varied in regard to all points.

  14. The personnel directly involved in the daily work with the cytology samples are: the lab auxiliaries, the cytodiagnosticians, and the lab physicians (i.e. cytologists, that is, physicians with additional training in cytology and/or pathology).

  15. Although Polanyi’s (2009) work on the tacit dimension and Dreyfus’s (1992) seminal work on the importance of the body in his critique of artificial intelligence are also relevant, I wanted to analyse and articulate the subtle variations of bodily relations to technology and technologically mediated perception embedded in daily practice and therefore found Ihde’s concept of multistability more useful.

  16. I have previously suggested that the rare cases where there is a perfect match between the cells and the classification constitute a form of ‘aesthetics of the exceptional’ since practitioners often called these cells “beautiful cells” (Forss 2007).

  17. Cf. Thorne’s (2001) critical discussion on the polarisation between holism and reductionism in nursing, and I would add that this discussion is also relevant in a clinical laboratories.

  18. I here paraphrase Galison's (2002) discussion on the use of images in science.

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Acknowledgments

I thank the cytology laboratory practitioners for making this study possible. I am grateful for the important criticism and fruitful comments on earlier drafts by Robert Rosenberger, Adam Rosenfeld, Kyle Whyte and the Technoscience Research Seminar group. Economic support for this work has been gratefully received the Swedish Foundation for Health Care Sciences and Allergy Research (Vårdalstiftelsen), the Swedish Cancer Society, and from the Board of Research for Health and Caring Sciences; the Board of Postgraduate Education, and the Department of Nursing, all at Karolinska Institutet.

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  1. Division of Nursing, Department of Neurobiology, Care Sciences & Society Karolinska Institutet, Department of Philosophy, Stony Brook University, Stony Brook, NY, USA

    Anette Forss

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Forss, A. Cells and the (imaginary) patient: the multistable practitioner–technology–cell interface in the cytology laboratory. Med Health Care and Philos 15, 295–308 (2012). https://doi.org/10.1007/s11019-011-9325-0

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