70 Complexity

One of the inspirations for more post-professional thought in healthcare has been the growing realisation of just how complex health and healthcare have become. So, as well as exploring the possibilities of unbundling the professions’ claims to goodness and expertise, post-professionalism also examines many of the other ‘logics’ of traditional Western healthcare that flow from this, especially the ways Western health professionals have traditionally dealt with complexity. This has become important given the gamut of healthcare practices now available to people, and the increasingly diverse ways people conceptualise what it means to be healthy.

Providing healthcare to a single person, never mind a large, diverse population, has always been complex ^[1][2][3]. But in recent years, the idea that social problems, like healthcare, are so complex and multi-layered that they are beyond the reach of service users, expert professionals, or even governments, has become a recurring theme ^[4].

Increasingly in the West, we see ‘tired, distracted patients struggling to manage their lives in the face of multiple conflicting challenges, with insufficient energy for the level of personal agency required to deal with the self-management approach’ ^[5]. ‘Each day on earth,’ Mary Cappello has written, is ‘an endless adjustment to there being too much or not enough’ ^[6]. But post-professionalism argues that these are symptoms of the system itself, since ‘every system is perfectly designed to get the results it gets’. (This quote often attributed to business commentator David Hanna, but there are many variations of this idea in the literature.) In our drive for personal responsibility, autonomy, productivity, and efficiency, we have created what effectively amounts to a care crisis ^[7][8], that now seems to be leaving many people behind.

Paradoxically, it may be that the desire for orthodox health professionals to be seen to be taming the complexity of health and healthcare, with the same logic and reason that gave medicine its prestige and power, is actually contributing to the crisis ^[9][10][11]. Renee Fox has shown how healthcare students, for example, use a range of tactics, from reducing healthcare problems to probability-based, scientifically defined issues, and disregarding the affective, personal nature of the patient and the consultation’ ^[12]. But they are doing this out of ‘poorly disguised longings for a kind of control and certainty that, if it ever existed, is certainly long dead now’ ^[13]. We have put our faith in our ability to ‘master all things’ ^[14], and have learned to distrust ambiguity and uncertainty, in part because it makes us professionally vulnerable; a problem made worse when ‘certainties become destabilised’, and we engage in more complex ‘relational forms of knowing against a knowledge that espouses singular truths’ ^[15].

Post-professional writers like John Law and Annmarie Mol suggest that complexity exists when ‘things relate but don’t add up’, when ‘events occur but not within the processes of linear time’, and when ‘phenomena share a space but cannot be mapped in terms of a single set of three-dimensional coordinates’ ^[16]. Complexity of this sort requires tools adequate to the task of not capturing and collapsing the surplus space of unpredictability, uncertainty, and opacity, but transgressing it ^{[17][18][19][20]}.

A plethora of approaches to this have emerged in recent years. In Chapter 6, I cited Avital Ronell whose work on the value of stupidity in thinking ^[21], has shown how hard it is to retain the tension of openness to difference. Ronell argues that we grasp for meaning in transcendent signifiers (God, patriotism, reason, one’s profession), and forms of shallow gratification (consumption, shopping, food, exercise), as ways to salve ‘the wound of non-meaning’ (ibid). Ronell’s call is for us to embrace the inappropriable; resisting the urge to collapse non-meaning with shallow logics.

A similar argument has been made by Erin Manning in her book Relationscapes ^[22]. Here, Manning argues that every action carries a thousand risks that must be resolved for movement of any sort — physical, conceptual, or existential — to occur. But the ‘juice’ of life is not in the resolution of the thousand tensions into a definitive answer, but in the instances before movement manifests, when the risks of a misstep are held in tension. Alfred Hitchcock used to say that a real thriller is not one where the bomb goes off under the table of the couple sitting in the restaurant, but when it does not. Manning’s argument is similar: life is in moments pregnant with possibility and resolution, or the collapse into meaning — as Ronell might say — only serves to bleed the moment of its life force.

Philosopher Jacques Derrida suggested that the ambiguity that is an inherent part of decision-making, acts like a surplus capacity that defies our desire to know and capture the answer we seek. He called this undecidability, and suggested it is the reason why we have experts in society ^[23]. We need judges, for instance, not because sentencing can follow standard formulae in which Crime A deserves Punishment B. Rather, we need judges precisely because decisions often defy formula. Nothing hangs in the balance when a conclusion can be reached by means of rational argument, algorithm, or calculation. We need judges to help us navigate the ambiguities and complexities of the case that cannot be resolved with routine formulations, standard rules, linear pathways, predictable logic and, sometimes, even reason.

Barbara Gibson applied Derrida’s undecidability to her post-critical analysis of physiotherapy ethics, opening ethics to possibility and doubt ^[24]. Anna Rajala suggested that because physiotherapy is a ‘material’ practice, it ‘ought to be understood as more than a mere economic exchange of services, technical knowledge and skills’ ^[25]. This is because ‘it involves working on, with, for, around and through bodies that encounter, interact with and touch each other, move and are moved physically, psychologically, socially, culturally, biopolitically, and emotionally’ (ibid). And in his doctoral thesis, Filip Maric spoke of the violence we do to things when we attempt to diagnose, label, capture, assess, and treat people in physiotherapy ^[26]. Emmanuel Levinas — a major influence on Maric’s work — argued that when ‘the known is understood and so appropriated by knowledge… [it is] freed of its otherness’ ^[27][28].

Annemarie Mol has written extensively about the multiplicity and contingency of health care ^{[29][30][31][32]}, but most especially about the ‘fuzzy, complex, and adaptable styles of knowing and acting that are crucial’ for clinicians in clinical settings ^[33]. In The logic of care, Mol advanced the idea that the choices customers face in navigating the complexities of healthcare are always based on limits imposed by healthcare itself (i.e., clients/patients never have complete freedom) ^[34]. And so, healthcare functions as a tool for limiting care rather than opening it up. Mol asks why care operates this way, if not because it is based on an economy of reason and resources?

Mol’s work draws on Georges Canguilhem groundbreaking 1966 study The normal and the pathological ^[35]. In the book Canguilhem argues that our faith in the biological basis of normality is misguided, suggesting that new norms are always being created, and people live in a ‘multiplicity of norms’ ^[36]. Rather than being fixed, norms and pathology are ‘dynamic, adaptable, and diverse’ (ibid). Their existence is only evidence of a system designed to give artificial stability to the biological sciences; a point that Foucault interrogated extensively ^[37][38].

The reason why many post-professional writers are at pains to critique programmatic thinking — a phenomenon increasingly at the heart of late capitalist approaches to healthcare — is because the rejection of the idea that practice can be guided by singular, fundamental truth, demands a ‘mega-ethicality’ in people ^[39]. It is much easier to live and work under conditions where someone else tells you what is good and bad, right and wrong. But if professionals are prepared to let standard rules and guidelines govern their ethical reasoning, they cannot, at the same time, claim ethical ‘goodness’. Falling back on standardised assessments, evidence-based ‘best practice’ mandates, pre-formulated care plans, and even rules of professional conduct, can have the perverse effect of reducing the ethical conduct of practitioners. As the anxieties of undecidability are substituted for formulaic ways of thinking and acting, we increasingly ‘evacuat[e] ethical decision making’ ^[40], and substitute complexity for systems and structures that are de-contextual and reductive.

‘Post’ perspectives argue that all attempts to prescribe a method for living, diagnosing an illness, or treating a patient, are thinly disguised forms of cultural imperialism, particularly when group morality is tied to rules defined by reason and logic ^[41][42][43]. Instead, we should look to celebrate the ambiguities, paradoxes, and differences inherent in health, as it is, not as a group of elite professionals would like it to be ^[44].

Many of the authors now looking at the value of ambiguity and complexity in healthcare have been heavily influenced by the work of French philosopher Gilles Deleuze, who argued that we should always look to open space for diversity and difference, and limit the extent to which we close these off ^[45][46]. Deleuze believed we were naturally drawn to collapsing ambiguities; a process he called territorialisation. But equally, and with effort, we could recognise our habit and work to deterritorialise ways of thinking and practicing. The goal, he argued, was to create spaces for thinking and action that were unencumbered by rules and regulations, barriers and obstacles (what he called ‘smooth space’ rather than ‘striated space’).

Along with his long-time collaborator, Félix Guattari, Deleuze argued that our tendency towards reason and logic had created a misunderstanding about the way learning and knowledge really worked in society ^[47]. Deleuze and Guattari suggested that Enlightenment thinking had led us to think of learning as ‘arborescent’, or tree-like, with knowledge grounded in deep roots, that formed large branches, and from these endless specialised stems grew. The purpose of arborescent thinking was to produce the shiny fruit (the expert professional) as the end product of years of growth and maturation. Deleuze and Guattari suggested that this metaphor reflects the linear, progressive fantasy of scientific reason, but ignores the true messiness of learning and life in general.

Deleuze and Guattari argued, instead, that society worked more rhizomatically, or like a virus or a swarm. Like the networks of fungal hyphae that spread out for miles underground and give life to the soil, Deleuze and Guattari argued that there was no beginning or end to a rhizome; we always occupy multiple ‘middles’. People can reside on multiple nodes in the rhizome at any one time (at any one moment a person could be a patient undergoing a CT scan, a mother, a physiotherapist, a carer for an elderly relative, a goalkeeper for the local football team, etc.). People are no longer fixed entities, but assemblages of organic and inorganic ‘intensities’: networks of connections and associations, arrivals and departures, connections made and connections lost; emergent entities with properties that cannot be reduced to their individual components, as Barbara Gibson explains;

’Deleuze and Guattari reimagine the static individual of fixed identity in terms of assemblages that can be thought of as temporary collections of heterogeneous human and non-human elements that might include bodies, objects, ideas, animals, places etc., ad infinitum’ ^[48].