The ideal of individual choice has lately been enthusiastically embraced in health care as it tries to provide a counterweight to the overbearing paternalism that has characterized patient-professional relationships for so long. Furthermore, patient choice fits well with the drive towards market-based reforms to increase efficiency and competition and hence reduce the demands of a costly service system on cash-strapped governments.
Annemarie Mol’s The Logic of Care is a wonderfully perceptive book that sensitively deconstructs the mantra of patient choice in contemporary health care. In criticizing the maxim of choice, Mol steers clear of a familiar argument that denies patients the emotional and cognitive abilities to make correct assessments about life or death questions. Rather than focusing on patients’ abilities, Mol shows that people in care practices do not primarily figure as subjects of choice but as subjects of a much more nuanced meshwork of activities and judgments. So, instead of ‘pushing professionals back into their cage’ in the choice model, or allowing them paternalistically to do whatever they want, this book investigates the dense texture of a care practice that emerges around crucial substantive questions: how to live well, what to die from, how to shape good care?
Mol’s ambition is not to supplant a monolithic and abstract choice-based discourse with another theoretical framework. Her approach is case based - focusing on the treatment of/life with diabetes - and Mol does not wish to stretch the logic of care articulated in her study beyond the boundaries of that particular case. However, as the book unfolds and the contrast between the logic of choice and the logic of care is illuminated from a sequence of perspectives, we start to appreciate how very different these two worlds are, and, in fact, how limited and low-dimensional a choice-driven patient experience is.
A first chapter approaches the logic of choice from a commercial, market-led point of view, where patients are segmented into `target groups’ that have specific requirements for clearly defined products or services, the effectiveness of which can be judged by their ability to improve health and banish disease. In the logic of care, by contrast, care is an interactive, open-ended process which cannot be judged on results only. Sometimes we need to accept that some problems keep on shifting, that health remains out of reach. In those cases, good care boils down to a persistent, unpredictable, forgiving effort to improve the situation of a patient, or to keep it from deteriorating. Annemarie Mol juxtaposes the simple segmentations and seductive messages brandished by the biomedical industry with the unavoidable messiness of care: “Care is not attractive. Let me underline this, even good care is not attractive. If only because as a patient, you cannot just buy it as if it were a product for passive consumption. Instead you have to engage actively in care, painfully, enduringly, and as a prominent member of the care team”. Rather than to go along with the promises of freedom from pain and constraint, professionals operating within a logic of care will explicitly address the fear of failure: “a caring professional reminds you that, no matter what statistics may promise, everything is erratic (...). Unpredictable. Do your best, but if this turns out not to be good enough, let go. Don’t take the world on your shoulders”. The art of care is to act without seeking to control, against the horizon of the one and only certainty: in the end, you die.
This first chapter is exemplary for Mol’s approach throughout the book. It’s an intricate and, for me, very persuasive way of thinking. In fact, the logic of care is not so much a way of `thinking’ as it is a way of being in the world, humane in its focus on the down-to-earth and the achievable, subtle in its attention for the contingent, the unclassifiable and the lived reality of bodies, and somewhat blunt in its acceptance of failure and mortality.
The following chapter starts out from the civic version of the logic of choice. A democratic model of citizenship puts patients and professionals on equal footing. But it’s only the healthy, controllable part of patients’ bodies that anchors their potential for emancipation. Thus patients may only hope to be citizens in as far as they are healthy. Mol argues for a logic of care that considers `living with a disease’ rather than `normality’ as the standard. The body in the consulting room is not a causally coherent entity, is not something that can be subjected to metabolic control without further ado. Rather, it requires us (patients and professionals) to be attuned to the myriads of ways in which we can relate sensitively and wisely to our surroundings, the artefacts (such as a diabetes pen) that populate it and the flows (of food, of bodily fluids) that interconnect body and environment. Staying in metabolic balance, therefore, does not depend on control but on dispersed coordination, inside and beyond the skin.
The logic of care is pragmatic and rooted in the frank question `how to live?’, `how to live with/in a body that is both fragile and able to experience pleasure?’. When patients are confronted with a potentially lethal disease, they tend not to mind about choice: “something else is going on. Once dead you have no choices left at all. And life with diabetes may be tough, but it is life. It may, in many ways, be a good life too. That is what people seek. In that context their first concerns is not with who is in charge, but with what to do.”
Next, Mol takes on a simplistic, linear view on the work of a medical professional who is supposed to give information, after which the patient can assess his or her values and come to a decision. Technologies insert themselves in that relationship in an ostensibly transparent and value-free way: if you choose where you want to go, your technologies will get you there. Science-based `facts’ provide solid beacons in the therapeutic trajectory. In contrast, what goes on in a logic of care is more a question of `doctoring’ in the sense of tinkering with bodies, technologies and knowledge. Technology is as unpredictable as human beings or diseases are. They always generate forms of pain and pleasure nobody expected and they change expectations. Objective facts do not exist: “for the logic of care gathering knowledge is not a matter of providing better maps of reality, but of crafting more bearable ways of living with, or in, reality.”
In the logic of choice all fluidity is located in the moment choices are being made. At that moment the facts are given, and so too are the possible courses of action. In the logic of care you may want a lot, but reality does not necessarily conform. Life is viscous throughout. No variable is ever fixed. The `balance’ sought is something that needs to be established, actively, by attuning viscous variables to each other. This is what the tinkering is about. And it is here where Mol sees a potential for opening up the monopoly of professional groups over expertise: “Let us, somehow, share the doctoring. Let us experiment, experience and tinker together - practically.” No actor in this constellation acts alone: in the logic of care the action moves around. “One moment you care and the next you are taken care of. Care tasks are shared in varying ways. (...) The fact that that patient has a disease affects what needs to be done, but it does not absolve the patient from playing an active part in the doing.”
In the final chapter, Annemarie Mol unravels the paradoxical relationships between the individual and the collective. Orthodox public health policy is based on aggregating individualized bodily indicators of health or disease by means of the tools of epidemiological research and the tools of statistics. So, individuals are pre-given and collectives emerge from them through numerical operations. In the logic of care the collective is the starting point: “(...) categorizing is not like collecting. It is not a question of aggregating individuals with characteristics that are already there. Instead, categorizing is a matter of differentiating between collectives.” In that process some individual characteristics come to be framed as relevant. The list of attributes (and thus the relevant categories in which one might fit) is left open. Again, categories are not taken to be fixed reflections of a given reality but pragmatic tools to work with, to be fine-tuned to the task at hand: “In the logic of care, the crucial question to ask about a category is whether or not is takes good care of you.” As a result, Mol thinks a lot of public health campaigns that try to persuade individuals to `choose a healthy lifestyle’ do not make relevant differentiations. They address people as if they are all equal. Vice versa, care given to individuals who most need it rarely improves public health. That is even more true for the type of care that `only’ increases quality of life and does not affect national mortality statistics. Mol concludes that “public health does not improve as a result of caring for people who happen to have a disease. It improves from interventions that keep the healthy healthy. Individuals and populations need completely different types of care.”
There is more in this rather slim volume than can be done justice to in even a lengthy review. I found the Annemarie Mol’s logic of care to provide fresh and very rich perspective on the complex relationships between patients, diseases, medical professionals, knowledge and technological artefacts. It is a pragmatic, experimental and fluid approach that does not start from abstract dichotomies (active vs passive, health vs disease, thinking vs action) but from the thick textures of daily life practices. Her book is an appeal to practitioners and patients to live up to the challenges of `good care’. From professionals this requires patience, mutual respect, and the ability to take nothing for granted. From patients it demands energy but also the ability to resign to their own suffering. Annemarie Mol’s is a very rich, sober, intelligent and humane critique on contemporary approaches in medical practice and public health. Recommended without reservations.