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Nursing and the Reality of Politics

Nursing and the Reality of Politics

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Nursing Inquiry 2009; 16(3): 261–272

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Nursing and the reality of politics
Clinton E Betts McMaster University, Hamilton, ON, Canada Accepted for publication 14 October 2008

BETTS CE. Nursing Inquiry 2009; 16: 261–272 Nursing and the reality of politics Notwithstanding the remarkable achievements made by medical science over the last half of the twentieth century, there is a palpable sense that a strictly medical view of human health, that is one founded on modernist assumptions, has become problematic, if not counterproductive. In this study, I argue that as nursing continues to eagerly welcome and indeed champion medical epistemology in the form of knowledge transfer, evidence-based practice, research utilization, outcomes-based practice, quantifiable efficiency and effectiveness, it risks becoming little more than a medical science addendum and indeed one that inherits the problems now facing contemporary medicine. The purpose of this study then is to attempt to resituate nursing as a discipline at work within an ontopolitical matrix of radical democratic pluralism. I begin by tracing a philosophical line from Kuhn’s paradigms to Bloor’s strong programme of Sociology of Scientific Knowledge. Following this, I attempt to explicate the thought of Bruno Latour as a philosophical alternative to Sociology of Scientific Knowledge. Next, I outline the radical pluralism of William Connolly in an effort to demonstrate its similarity to Latour’s philosophy and finally how such a position is germane to contemporary nursing and the reality of politics. I do this with reference to the controversial issue of illicit drug use and harm reduction. In effect, I argue that such an issue cannot be dealt with using scientific evidence alone, but rather requires a philosophy of advocacy, what I term democratic advocacy, that is capable of responding to the politics of suffering, which is to say suffering that results from identity ⁄ difference. Key words: advocacy, democratic theory, nursing knowledge, philosophy, politics.

In 1970, Eliot Freidson (1988, xvi) claimed that ‘in one way or another, the profession of medicine … has come to be the prototype upon which occupations seeking a privileged status today are modeling their aspirations’. Since the publication of Freidson’s major work, Profession of medicine, it has been argued that doctors have lost a significant amount of their power and autonomy (deprofressionalization, see Freidson 1984), yet there is little denying that the institution of medicine still remains the paradigmatic profession. Moreover, one might safely suggest that, despite some reduction in physician autonomy in practice, the institution of medicine has not only retained its organizational power to define, control and set the agenda of health and illness in society, but indeed has in many respects, with the rise of evidencebased medicine, knowledge transfer, research utilization, outcomes-based practice, quantifiable efficiency and effecCorrespondence: Clinton E Betts, School of Nursing, Faculty of Health Sciences, McMaster University, 1200 Main Street West, Hamilton, ON, Canada L8N 3Z5. E-mail: <bettsc@mcmaster.ca>

tiveness, furthered it. Holmes et al. (2006, 181) explain that ‘The health sciences take their lead from institutional medicine, whose authority is rarely challenged or tested probably because it alone controls the terms by which any challenge or test would proceed’. Moreover, that agenda is a thoroughly modern one, which is to say: objective, reductive, rational and progressive, or put succinctly – techno-rational progress. ‘The most popular and common ‘‘grand theory’’ of modern medicine is the tale of the body as a machine. Modern medicine is Cartesian in spirit’ (Tsouyopoulos 1994, 272). Notwithstanding the remarkable achievements made by medical science over the last half of the twentieth century, there is a palpable sense that a strictly medical view of human health, that is one founded on modernist assumptions, has become problematic, if not counterproductive (Scott and Conn 1989). As Fredriksen (2003, 287) puts it ‘The success [of medicine] is, however, accompanied by a just as undeniable story of disappointment, crisis and medicalization … benefits and side-effects of medical intervention are of the

Ó 2009 Blackwell Publishing Ltd

which is to say sociopolitical context in which knowledge is generated. I shall attempt to explicate the thought of Bruno Latour as a philosophical alternative to SSK. to discipline patients with knowledge: Nurses are at the flexing point of the state’s requirements and of individual and collective aspirations. if you will. what Illich (1976) termed social and cultural iatrogenesis. to name only a few). Next. to put it in Foucaultian terms. and perhaps to a degree postpositivist. without a critical appreciation of the (social) nature of knowledge and its application. as apposed to Cartesian rationalism. outcomesbased practice. Yet. Callahan 2003. However. Medicine is. there is a very real potential that an uncritical regime of knowledge transfer and application could not only disrupt the act of advocacy. Consequently. I shall outline the radical pluralism of William Connolly in an effort to demonstrate its similarity to Latour’s philosophy and finally how such a position is germane to contemporary nursing. from Marxist and critical theory to feminism and postmodernism. I must make reference to a sociologist (David Bloor) who took Thomas Kuhn quite literally. Conrad 2007. as Roy Porter (1998. Following this. Add to this the fact that. although sympathetic in many respects (to constructivist theory). It is also important to recognize that the work I am presenting (Latour and Connolly) is not without serious critics. 536) The purpose of this study. rather than a mere adjunct to medical practice. Illich 1976. research utilization. is to attempt to resituate nursing as a discipline at work within an ontopolitical matrix of radical democratic pluralism. ‘The presentation of medical science as a progressive march forward in the conquest of illness to the benefit of humankind fails to recognize that medical knowledge is never disinterested’ (Annandale 1998. That is. legitimated. Giere (2006). in the rush to facilitate knowledge transfer and application. but also serve to foster the opposite effect. To accomplish this. as well as from within medical science itself (Foucault 1973. philosophers and theorists such as Haack (2003). Ruse (1999) and numerous others. the agenda of advocacy that nursing has recently assumed. knowledge transfer. However. Markle and McCrea 2008. nurses constitute a fullyfledged political entity making use of disciplinary technologies and responding to state ideologies. with a philosopher of science (Bruno Latour) who has attempted to dispense with postmodernism altogether (Latour is best described perhaps as a non-modernist) despite once being labelled a postmodernist. Moreover. might well be lost. that is radically. framework of medicine. that is evidence-based practice. Fluet. or certainly rendered impotent. nursing cannot but remain subsumed under the largely positivist. before I do that. 718) concluded in his landmark work The greatest benefit to mankind: A medical history of humanity ‘medicines finest hour is the dawn of its dilemmas … its triumphs are dissolving in disorientation. may not find what 262 Ó 2009 Blackwell Publishing Ltd . Szasz 2001. two theorists who come from very different perspectives (again. I shall attempt to bring together a political scientist (William Connolly) whose thought draws upon the work of numerous postmodernists and poststructuralists. quantifiable efficiency and effectiveness. epistemology and practice. disseminated and applied will perhaps lead to a more sophisticated and hence productive view of nursing as a unique profession. which is to say suffering that results from identity ⁄ difference. despite years of important critique from diverse disciplinary and theoretical perspectives. I do this with reference to the controversial issue of illicit drug use and harm reduction. It is my hope that this approach will provide a framework for future work concerning nursing theory. and happily embraced relativism.(Perron. In other words. transfer and application. As nursing continues to eagerly welcome and indeed champion epistemological medicine. Although nursing certainly does require knowledge to be practiced. I argue that such an issue cannot be dealt with using scientific evidence alone. still the dominate epistemology and a problematic one at that. Medicine has led to inflated expectations. 1988. Barsky. Candib 1995. I will begin by tracing a philosophical line from Kuhn’s paradigms to Bloor’s strong programme of Sociology of Scientific Knowledge (SSK). Lupton 2003. It should be noted that the primary aim of this study is to build (or perhaps introduce is a better way of putting it) a theoretical foundation by triangulating. with nursing situated closer to the patient than any other healthcare profession. They occupy a strategic position that allows them to act as instruments of governmentality. neither is it without social and political side effects. Freidson 1988. In effect. which the public eagerly swallowed: medicine will have to redefine its limits even as it extends its capacities’. that is capable of responding to the politics of suffering. in many respects. to which I would add. and Holmes 2005. 5).CE Betts same root … technological objectivation of diseases’. but rather requires a philosophy of advocacy. Or. then. Hacking (1999). philosophy of science and political theory) yet appear to arrive a similar conclusions. medicine has been largely undeterred in its modern mandate of knowledge production. I contend that a better understanding of the larger. it risks becoming little more than a medical science addendum and indeed one that inherits the problems now facing contemporary medicine. both patient rights and existential (Gaylord and Grace 1995). For example. what I term democratic advocacy.

I would be tempted to say that the only sources to quote and to dispute are the articles and books I am presently working on. It is the latter that concerns me here. p. and still is.g. to the social epistemology of Steven Fuller and. Like the choice between competing political institutions. to critics who accused him of relativism. that between competing paradigms proves to be a choice between incompatible modes of community life. in a recent study. Latour (1999b. paradigms into what he called exemplars and disciplinary matrices (Kuhn 1977. Bloor (2007. though Kuhn no doubt considered it a clarification. Kuhn’s work and the controversy that often surrounds it has spawned a number of differing schools. the strong programme in particular. that is. I do not believe that relativism constitutes a danger. He argues for a symmetrical understanding. 94) of science can. all of them attempting to deal with relativism in one way or another. relativist relativism – or. Relativism certainly is at the centre at Bruno Latour’s thought as well. 251) not only accepts the label of relativist. by itself. paradigm.Nursing and the reality of politics I have to say entirely convincing. it signalled the end of positivism as a viable philosophy and. introduced the now ubiquitous concept. To put the point clearly ‘All knowledge always depends on society … society is the necessary vehicle for sustaining a coherent cognitive relation to the world. of scientific knowledge in that both the successes and failures Ó 2009 Blackwell Publishing Ltd Latour’s early work. not the consequence. 99) Indeed Bloor (1999) does in fact label Latour’s work SSK. and acceptable results are social conventions … there is no Archimedian point’ (Bloor 1991. relationism – presents no difficulty in principle …. moreover. and indeed. following Structure. chapter or book is representative of my position. as a means of getting at the thought of Bruno Latour. Never by itself. is however. In any case. This is to say that ‘scientific theories. I shall present the ideas. For example. however (e. I do not have the time and space in this study to outline the many of all the changes Latour’s thought from Laboratory life: The construction of scientific facts (with Latour and Woolgar 1986). his Second thoughts on paradigms (Kuhn 1977) as well as his more recent work. If the question of relativism is insoluble. of course. failings and mistakes of science and scientists are due to sociological reasons. Bloor then. he embraces it ‘Despite this growing consensus. he writes in Reflections on my critics ‘it is emphatically not my view that ‘‘adoption of a new scientific theory is an intuitive or mystical affair. On the contrary. or reworked. and indeed. I think a properly formulated relativism should be warmly welcomed’. Be that as it may. a landmark in the philosophy of science. Laudan and others. when a dispute or controversy arises between two scientific theories (paradigms). Relationism will serve as an organon for … negotiations over the relative universals that we are groping to construct. so in paradigm choice – there is no standard higher than the assent of the relevant community …. but always through the mediation of another …. 463). especially a relation of the kind we take for granted in our science’ (Bloor 1999. 110). which claims that the errors. and his eventful paradigm. Indeed following the furor of Structure. This is the problem then of explicating Latour’s thought. the symmetry principle. In other words. seems to take the relativist views of Kuhn’s work quite literally. Science in action). 114) Then there are his responses. from the postpositivism of Lakatos. the SSK. we can never use the outcome – Nature – to explain how and why a controversy has been settled. some have suggested. either reducible or irreducible to anything else. the decision to accept one over the other as true is done for sociological reasons rather then epistemological. or course. Quite obviously. should be explained sociologically. (Kuhn 1970a. Kuhn changed. methods. 43– 4). does not go far enough. In many respects. there are those who would simply dismiss it altogether. These later works of Kuhn. In essence Bloor claims that the weak programme of SSK (begun by Robert Merton).(Latour 1994. However. 115) thought it at attempt to move ‘Beyond’ SSK and in so doing he admits that Bloor’s critique makes: my defence more difficult since I would be at great pains to say which paper. a matter for psychological description rather than logical or methodological codification’’’ (Kuhn 1970b. The problem with Kuhn. to put it more elegantly. Indeed. his Postscript (to the second edition of Structure). There is what he appears to express in Structure : As in political revolutions. might well represent a significant retraction of what was said in Structure. not unlike with Kuhn. but. seems to position itself squarely within the Strong Programme tradition: Since the settlement of a controversy is the cause of Nature’s representation. to Science in action: How to 263 . welcome any criticism that comes. 261). BEYOND PARADIGMS Thomas Kuhn’s (1970a) The structure of scientific revolutions was. figuring out what he means. figuring out what he meant by it. Moreover. as one example of the strong programme of SSK. Yet he does not welcome relativism so much as it transforms into something much more productive – relationism: Nothing is.(Latour 1987.

and then maybe to the United Nations. We might even refer to collectives of hybrids. Viewed in this manner.CE Betts follow scientists and engineers through society (Latour 1987). ‘be the circumstances of’: these are some of the verbs that signal the shift in attention from the modernist to the nonmodernist idiom. or created by the character that is the focus of attention. 1999b. nonhumans) can be shown to extend agenda and agency-like behaviour upon humans as well. to say nothing of his numerous studies. Indeed. Latour characterizes them as quasi-objects (or quasi-subjects). Thus. the aggregate of I’s in I think therefore I am are separate and distinct. perturbed. (Latour 1999a. to suggest that things (non-humans) have intentionality (Latour is certainly not an animist). and subjects. they are in a modern state of purification. However. or two distinct entities that interact only in that the subjective is the knower. tion. and attempt to move ‘Beyond’. 29) puts it ‘the modern Constitution invents a separation between the scientific power charged with representing things and the political power charged with representing subjects’. and from there to the University of California at Irvine. humans are better off appealing to nonhumans’ (Latour 1994. justice and power. things. For example: The smallest AIDS virus takes you from sex to the unconscious. Rather than speaking of things-in-themselves though. by Latour. while commonsensical for us from a Cartesian position. let us not mix up knowledge. 122) claims that: there is no other way to define an actor but through its action. the modern world is little more than a cosmic civil court proceeding intended to adjudicate disputes and maintain order. Newton ‘happens to’ gravity. And moreover. ‘intermingle’. the manipulator of the objective. is not with out its philosophical problems. the human and the nonhuman. in Latour’s terminology. ‘coalesce’. Pasteur ‘happens to’ the microbes. a process that Latour refers to as mediation. SSK. or nature. 1999b. Let us not mix up heaven and earth. and there is no way to define an action but by asking what other actors are modified. in addition to the utilitarianism of science in fulfilling the growth and development needs of human beings. as a web of reality – a common world as it were. Rather. 282) Hence. things (objects. an appeals court as it were. again media- Though we would not have any problem suggesting that subjects have an effect on objects. or networks of connectivity. ‘happen’. rather than being the simple product of an internal free will. they seem to say. rather than thinking of human beings as the only actors (Latour uses the term actants as in actor network theory) with agenda and agency in a universe of inert things simply waiting in situ to be acted upon. in the rather inevitable case of dispute. ‘bifurcate’. It might be argued that intentionality. transported. Every scientist knows in practice that things have a history too. laws and knowable processes. human ⁄ non-human or again quasi-objects ⁄ quasi-subjects. 2–3) LATOUR: BEYOND THE MODERN CONSTITUTION Latour’s original target is the founder of both science and the modern world – Rene Descartes. that is Latour’s point – we have never been modern. the chemistry of inert gases. Latour (1999a. fact and fiction (fetish) are dissociable. Without this constitution.(Latour 1994. By all means. subjects and objects are distinguishable. then to Africa. tissue cultures. However. or subject ⁄ object. Moreover. ‘negotiate’. In other words. they are two extreme poles. Pandora’s hope (Latour 1999a) and finally to Politics of nature (Latour 2004). interest. is just as much an external (structural if you will) set of influences and processes. 23). transformed. in case of doubt. DNA and San Francisco … Press the most innocent aerosol button and you’ll be heading for the Antarctic. 276) asks ‘Is the modernist … imprisoned and enchained by his delusionary and muddled belief?’. for Latour. The belief that belief and truth are distinct. not unlike that of non-humans. and more specifically ´ the Cogito (I think therefore I am). for modernism ‘Nature and Society must remain absolutely distinct: the work of purification must remain absolutely distinct from the work of mediation’ (Latour 1994. nature with all of its properties. we find that objects have effects on subjects. Dualism in its most pure form we might say. that they both have histories if you will. ‘ally’. Moreover. ‘According to the [modern] constitution. it is suggested that human intentionality. I’s and things join forces to generate hybrids of coexistence. it also services them by providing a standard of judgment beyond themselves. the global stage and the local scene. As Latour (1994. through to We have never been modern (Latour 1994). 264 Ó 2009 Blackwell Publishing Ltd . Although there is no attempt here. the user. 32). but this fragile thread will be broken into as many segments as there are pure disciplines. nature and society (subject and object) have always been interacting and communicating reciprocally. 1999b. to form hybrids of natural ⁄ social. nature and society are separate. the mountain ranges of Lyon. Latour (1999a. I will then sketch only the major elements that demonstrate its differentiation from. the engineering of the modern world would simply not have been possible.

utilized. 235). it provides possibilities if you will. Rather. are skills used to ‘constitute the common world and take responsibility for maintaining the plurality of external realities’ (Latour 2004. ‘Not everything is political. different hybrids and unique substances come into being. or hybrids. postcolonialists and the like to gain some metaphorical traction. so long as we agree to redefine politics as the entire set of tasks that allow the progressive composition of a common world’ (Latour 2004. where Science refers to ‘the politiciszation of the sciences by … epistemology in order to make public life impotent’. the construction of a social order is not. in that new elements. while the sciences ‘in the plural and lowercase’. Moreover. are subject to the due process of a democratic political procedure.). but for the Nazi’s genetic and evolutionary knowledge represented certain ‘conceptions of nature’. however. to force – their way through. cannot be at all considered SSK in that for Latour. one must engage in politics. but politics gathers everything together. that is certainty. Thus. However. but indeed they are also given to change. been produced. or should not be. an evolution over time. Against the epistemology police. Most importantly. they (genetics and evolution) gained their use. they are not just social constructions). after all who is not against 265 . Latour does not argue that there is not realness to them (i. transformation. there is simply nothing that is distinctly social.e. the sciences. 17) Take for example. neutrality or any other kind of dualistic descriptor. like all relationships. the base configuration of reality. knowledge cannot be separated from ‘conceptions of nature’ and hence politics. reconfiguration. objectivity. Moreover. diverse elements that are all in effect some mixture. Latour’s more recent work then. In other words. Thus ‘we need to abandon Science in favour of the sciences conceived as ways of socializing nonhumans’. is itself political by the very nature of determining what will be knowledge. how such knowledge will be used and to be sure who is privy to it. alteration. by recourse to scientific authority and epistemology. and certainly not epistemology. or perhaps more correctly constructed with. and moreover such change is not a superficial phenomenon. The very process of knowing then formerly understood as a society ⁄ nature separation. the use of the term violence here might well generate some legitimate objection. with good reason. Scientists then are those individuals whose task it is to speak for. 55) To be sure.(Latour 2004. it has been used by postmodernists. By using objectivity to short-circuit political procedures. human and non-human. knowledge – indeed epistemology. and. composed of. for lack of a better way of putting it. and power.(Latour 2004. detachment. Indeed. perspectives and difference that it contains. in his opinion. but also that of politics … all for the most implausible political project: that of doing away with politics’ (Latour 1999a. and as well adopt a ‘politics defined by the progressive composition of the good common world’ (Latour 2004. there is only what he calls a collective or common world (Latour 2004). this common world should not be confused with universalism or absolutism. a reorientation of secondary qualities or mere appearances. an act of politics. In other words. Latour then distinguishes Science from the sciences. 215). rather he would ask: (i) how are they to be incorporated into a collective. or give voice to the non-speaking members of the collective – non-humans. ‘It is not only the practice of science and technology that epistemology has rendered opaque. but rather of a fundamental nature. Latour contends that heretofore epistemology. is for Latour an act of violence of sorts that short-cuts a necessary democratic ethos. knowing (scientific evidence) does not itself constitute a course of action. 1999b. which is to say change. or epistemology. to the detriment of the collective. The examples of ties between conceptions of nature and conceptions of politics are so numerous that we can claim. performed without recourse to the multiplicity of voices. nor for that matter is there a singular thing called nature. there is. invariably. By politics Latour means democratic deliberation in that ‘Thou shalt ensure that the number of voices that participate in the articulation of propositions has not been arbitrarily short circuited [by Science]’ (Latour 2004. for Latour. particularly Politics of nature. quantum mechanics or genetics. 249). that every epistemological question is also unmistakably a political question …. ignoring democratic due process in favour of Science rather than using scientific methods to produce what is then used (knowledge and knowing) in a democratic assembly process to construct reality (though or course it is certainly subject to change. The elements that constitute the collective are not only distinctive and dissimilar. altered and redefined. endow them with some natural right to determine or define reality based on such skills. the composition of this collective is. etc.Nursing and the reality of politics Hybrids of co-dependence and co-existence have always existed. namely Science. 53). perhaps. The point is that. Ó 2009 Blackwell Publishing Ltd 235). To give primacy to epistemology. Moreover. This does not. from which to then determine a course of action or construct a social order. diplomacy as he puts it. people had dared to confuse the sciences with this shortcut [Science] authorized by violence – and to do so in the name of the highest morality and the most delicate of virtures! With nature people sought to reason – that is. of the social and the natural. has been used instead of a democratic composition of the world. evolution. feminists. and (ii) what ‘conceptions of nature’ do they assume? Forgive the extreme example.

speed (Connolly 1995b) as well as a plethora of studies. In other words. and nature. The explication of this concept is carried out. he does not believe that such an understanding goes far enough. types and avenues of action – this is what Latour means by violence. behind all diversity is to be found a unity (a general agreement or consensus if you will) from which diverse elements. or confound the operational self confidence of the human sciences. we must first understand what he refers to as his ontopolitical matrix. emanate. is that it ‘first misrecognizes the paradoxical relation between a dominate constellation of identities and the very differences through which the constellation is consolidated and. Fundamental agreement is. 1995b. To know something says little about how such knowledge should be used. ‘A conventional pluralist celebrates diversity within settled contexts of conflict and collective action. the monotheistic or monosecularist basis of morality. and Connolly suspects that it is then ‘presumptions within [conventional pluralist] understandings must be reworked in 266 Ó 2009 Blackwell Publishing Ltd . a rationality. there is a much greater similarity between Latour and Connolly than mere anti-epistemology. xiii). or at any rate the one formerly held by epistemology. The problem with such thinking. his view of epistemology is quite similar to Latour’s: The primacy of epistemology short-circuits ontological issues by assuming that once the right procedure for attaining truth as correspondence or coherence or consensus is reached. representation. Often diversity is valued because putative grounds of unity (in a god. identity. as I have previously explained.CE Betts violence? However. The former pluralism. Moreover. Indeed. or a nationality) seem too porous and contestable to sustain cultural consensus’ (Connolly 1995a. or if it should be used as a constituent of the collective at all and again what conception of nature it entails. without deliberation (politics). 1995b. for the most part. despite a nod to the importance and even necessity of tolerance and the valuation of diversity. although it is to be found throughout his other work. which he associates with Alexis de Tocqueville (primarily Democracy in America). He contrasts conventional pluralism with what he calls the pluralization of pluralism or radical pluralism. 1995b. Latour is a constructionist. 2004) it might well be diversity. all the way down? If so.(Connolly 1995a. any remaining issues will either be resolved through that method or shown to be irrelevant …. Such construction must be democratic. CONNOLLY: RADICALIZING DEMOCRACY William Connolly is no more of an epistemologist than Bruno Latour. Before we can make sense of Connolly’s work. reason. or perhaps building is a better metaphor and at the same time building is politics. xiv). the shape of the economy. To paraphrase an old epistemology critique (Allen. potential differences. misrecognizes new possibilities of diversification by freezing moral standards of judgement condensed from past political struggles’ (Connolly 1995a. moreover social and political change. However. the basis of gender difference. effectively suppresses other forms. what Latour means to suggest. but rather at the very foundation upon which it rests. not necessarily fundamental agreement. The primacy of epistemology thereby treats the ideas of subject. simply because without epistemology (certain knowledge) the building of a common world must take account of the diversity within it. again for both Connolly and Latour. culture. in The ethos of pluralization (Connolly 1995a). for Connolly as well as Latour. and knowledge as if they were already fixed in their range of application. but not a social constructionist in that for him. for Latour. in Connolly’s view. the source and scope of rights. Connolly very much elevates politics. xiv) However. is that knowledge itself does not predict.(Connolly 1995a. or condition its use. derail. In summary then. To assume that one knows and such knowing constitutes a given action. These roughly correspond to modern and postmodern versions of pluralism respectively. while acknowledging a significant threat from various fundamentalist factions. or put differently. Latour’s constructionism refers to just that – constructing. there generally does: prevail a set of general presuppositions about the terms of national security. The attraction of this perspective resides in its claim to bypass issues that might otherwise contaminate. to the position of epistemology. like turtles. 1995b. the normality of heterosexuality. understands diversity to be the result of unity. such an understanding often presupposes some form of agreement or consensus with respect to fundamental sociopolitical concerns – a procedural framework if you will. Why I am not a secularist (Connolly 1999) and Neuropolitics: Thinking. what it contributes to a collective. second. and democratic politics in particular. 6) Connolly begins by recognizing that diversity or pluralism has become a well-accepted position in contemporary social and political thought. object. and the generic character of justice. there is nothing uniquely social and by extension there is nothing that is distinctively nature (they exist as hybrids of social ⁄ nature). does not only happen at a superficial level of apparent diversity. as we shall see in a moment. Although conventional pluralism often does recognize the difficulty or problem of accord and harmony regarding fundamental issues.

Responsiveness is then. Such a postNietzschean ethic resists oligopolistic control over the currency of morality. crucially. which is to say doing things differently. both theorists seek to transform the politics of reality. Even Bloor (1991. that is the sociopolitical discourse (science included) that assumes the existence of a stable (or semi-stable perhaps) reality which can be known and utilized by human beings. in his embrace of relativism. which is to say change over time as well as negotiation in place ⁄ time. It does not present itself as the single universal to which other ethical traditions must bow. and moreover. Although postpositivist thought is neither circumscribed nor invariant. ‘nothing is fundamental’ (Connolly 1995a. to rework their relations to the diversity of ethical sources that mark a pluralistic culture. while affirming the indispensability of ethics. there is no universally valid operating consensus behind difference. Hence. however. 62–3) Such a process or procedure applies equality well to innumerable other social norms. all conspire to not only refashion and reconfigure identity ⁄ difference. context. outlook and on and on. the procedure of Connolly’s ontopolitical matrix. the overwhelming majority of these proposals suggest that nursing as a practice is. pressing them to rethink the ethics of engagement and. transformation. This would be to commit the unspeakable blunder of thinking that conventions are things that are trivially satisfied and essentially undemanding’. NURSING AND THE REALITY OF POLITICS It should be clear at this point that. historical conventions and even indeed scientific cognitions. we might say. however. would not concede this: ‘to say that the methods and results of science are conventions does not make them ‘‘mere’’ conventions. Put differently.(Connolly 1999. ways of seeing it (culture or society) – dualism or the politics of reality. Connolly subscribes to a Nietzschean becoming over a Kantian being. one cannot have (an) identity without the existence of difference. 1995b. how to identify and actualize their societal mission. For him. xxiv) importantly democratic negotiation. there is no binding unity beneath diversity. critical responsiveness involves active work on our current identities in order to modify the terms of relations between us and them …. Nor does it imply that reality is merely a convention that can be constructed in an infinite number of ways. Enter the pluralization of pluralism or radical pluralism: an ethic of cultivation rather than a morality of contract or command. to use Connolly’s preferred idiom. the opposite of the multicultural ⁄ mono-natural way of viewing the world.(Connolly 1995a. For the majority of that latter half of the twentieth century. in which reality is determined (again constructed) by (democratic) political activity. a postpositivist enterprise. with political change. as Feyerabend (1975) put it. similar in many respects to medicine. ethical precepts. Indeed. politics is the act of determining what reality is. is sociopolitical negotiation and more Ó 2009 Blackwell Publishing Ltd 267 . in essence. or ought to be. It is. political patterns. as heterosexuals respond to the politics of becoming by which a previous history of medicalization and demoralization of homosexuality is reconfigured they are also pressed to acknowledge for the first time that heterosexuality is not firmly grounded in the universality of nature. which suggests that there is a single reality (nature) and multiple. there is no being. xxi). Knowing for Connolly then. As he puts it elsewhere: where tolerance implies benevolence toward others amid stability of ourselves. It does. For example. reality is an act of politics or again political construction. Moreover. xv). 1995b. nurse theorists and academics have been attempting to explicate a foundation upon which to rest nursing practice. that is durability and stability over time (or even at any point in time). perspective. Although this rather unsophisticated way of putting it might well seem trivial. into a reality of politics. it is what he terms critical responsiveness that makes the difference. mean that. only becoming. ‘Anything goes’. revolutions. As Cody and Mitchell (2002. and it cultivates critical responsiveness to difference in ways that disturb traditional virtues of community and the normal individual. and how to communicate it to others’. almost all of it does rest on some understanding of epistemology as a Translated. 1995b. comes a change in what constitutes reality. but indeed generate new and unimagined possibilities and potentialities to which a truly pluralist society must be responsive. it provides a prod and counterpoint to them. Rather. it is not at all. ‘everything depends upon how this paradoxical relationship [identity ⁄ difference] is negotiated’ (Connolly 1995a. 45). A number of philosophical and theoretical possibilities have been proffered as a viable foundation for nursing. the commands of a god. 4) put it ‘contemporary healthcare issues demand that nurses know who they are and what they are about. 1) and most importantly change. This does not mean that. for both Latour and Connolly. it judges the ethos it cultivates to exceed any fixed code of morality. It has also been important to many for nursing as a discipline to articulate a unified conceptualization of itself. like Latour. legal precedents. To say that reality is politics means that political configuration (societal construction) determines what reality is – monism or a reality of politics. 1995b.Nursing and the reality of politics order to reshape the pluralist imagination’ (Connolly 1995a. or the automatic outcome of normal sensual development. perhaps competing.

CE Betts foundational tenant. although perhaps it is more accurate to say that nurses have. We are perhaps witnessing the birth and early development of what might be called the next nurse. Pauly et al. our communities and. our health system. Most importantly though. in many respects. knowledge for what. In fact. autonomous. medical epistemologist nonetheless. For example. her use of the phrase ‘changes that need to occur’ is more problematic than it first appears. 22). they claim that ‘there is a disturbing trend in Canada toward disregarding the scientific evidence. as opposed to the new nurse (Salvage 1990). They conclude that ‘it is incumbent on nurses to insist on a harm reduction approach for such individuals in all settings’ (p. In effect. yes. potentially jeopardizing public health initiatives designed to improve the health of those who use illicit drugs’ (p. nurses that is. to use Dewey’s phrase. 454) guided primarily by evidence-based practice. More to the point. 20). much of the most interesting and to be sure important contemporary thought (I have attempted to address two cogent examples: Latour and Connolly) might be described as a shift away from epistemology – postepistemological thought if you will. skills for what. Gordon and Nelson (2005. 63) have recently called for an end to angels in nursing. communities and even cultures for the better. best practice guidelines and research utilization all set within a modernist agenda. and technical knowledge without this being considered the sign of an uncaring nurse or a ‘‘wannbe’’ doctor’ (p. nursing postpositivists. and politics is pretty well dead’. 22). suggest that ‘when nurses work in ethical climates in which negative attitudes and judgements prevail toward people who have substance use problems. The large-scale embrace of evidence-based practice (this is not to say that is has not been criticized) and all that comes with that (research utilization and so forth) seem to suggest nursing has just discovered. warfare. but rather fundamental conceptualization of what Connolly refers to as identity ⁄ difference or what Latour terms the common world. the epistemology industry. for the good of individuals and society. while nursing appears. and does everyone agree? The epistemology answer is simply. money. media. nurses need ‘more knowledge. neither Latour or Connolly deny that (small ‘s’) science can provide invaluable information for a society attempting to construct and ⁄ or reconstruct itself. there are things to be done. In an important sense. Again questions like. claiming that ‘only when freed of the virtue script can nursing assert its identity as a knowledge-based profession that is critically important to patient care’. 2) claims. it is a reconfiguration. The next nurse is ‘the advanced. a cause recently taken up by nursing leaders. good being of course a relative term. the delivery of health care may be adversely affected’. or things that can be done. the next nurse. 2) concludes the message with ‘Let’s follow Freire’s example and get political: use education to bring about the changes that need to occur in our profession. Recent development in nursing has suggested wide support for such an approach. the world’. to be only now embracing epistemology (or demanding access to it). as I have said. who now demand access to it. (2007. education and skills. Smadu (2007. medical. Ó 2009 Blackwell Publishing Ltd . Although few would debate the spirit of what Smadu is suggesting. Nelson (2006) even invites us. that we do proper research. perhaps not a ‘wannbe doctor’ but. in effect – scientific progress. in another recent issue of Canadian Nurse. is no less problematic. families. apply that knowledge and the result is the ‘changes that need to occur’. ix) once put it ‘the idea that the disinterested pursuit of scientific truth can be neatly separated from engineering. For example. subscribe to some variant of dualism. 23). it changes our political emphasis from stopping illicit drug use for the good of individuals and society. Although scientific evidence is certainly important in such an issue. as well as what kind of knowledge. though it is not really simple at all. 221) puts it as succinctly as I think it can be put. seem legitimate. or rather a political term that refers to a conception of reality. or reconstruction. and more skills’. been assistants in the medical epistemology industry. While Bartels (2005. or again the great majority of them. Canadian Nursing Association president Marlene Smadu (2007. Moreover. to ‘celebrate knowledge’ (p. in some manner. where subjects (societies) come to know objects (nature) and in so doing use such knowledge to intervene. quoting Paulo Freire. The age of ‘Nightingale angels’ is certainly coming to an end (Gordon and Nelson 2005) and while this is probably a good thing. historically. which require a change not only in superficially diversity. generate knowledge. just what are these necessary changes that are so clearly needed. of the commonly held identity – drug user. to tolerating some level and emphasizing the reduction of the harm associated with drug use. 21). which in some respects I am suggesting a return too. that ‘Education is THE political activity’. discussing the evidence for harm reduction policies. I suggest. Curiously. education for what. in a recent issue of Canadian Nurse. I contend that harm reduction is an act of politics that redefines drug use in our society and our response to it. transfer that knowledge. more education. For example. in the lives of individuals. moreover ‘nurses can reclaim their scientific. expert professional armed with a 268 sophisticated knowledge base’ (Betts 2007. As Rorty (2004.

(Gaylord and Grace 1995. convincing and as well. Other essential and legitimate factors that affect policy-making include ideologies … beliefs … and interests’ (p. epistemologists perhaps. Advocacy for nursing stems from a philosophy in which nursing practice is the support of an individual to promote his or her own well-being as understood by that individual. for those of us that do. Mangham (2007b. Gaylord and Grace (1995) are correct when they suggest that nurses are in the best position to be advocates for patients. democratic advocacy is similar to both rights and existential advocacy. Indeed. in an effort to reduce the difference between us and hence change our ‘treatment’ of them? Are we not reconstructing a reality. Again. the knowledge transfer ⁄ application of the former (harm reduction) over that of the latter (prevention and treatment)? Is it not more than merely knowledge and evidence. developed. what is and is not utilized. that now situates drug use and our knowledge of it within a web of connecting ⁄ interconnecting factors? Such advocacy. as defenders of nursing advocacy often do. Kall et al.Nursing and the reality of politics The point that I endeavour to make is that this is not simply a knowledge transfer ⁄ application issue at all. debate. self-expression. they are antithetical ideologues (remember Hwang admits that ideology is legitimate) who. contesting the consensus. presumably. What is it then that makes us choose. To put it another way. Hwang admits that ideology is a ‘legitimate factor’ in social decision-making. endorsed. And 269 . and how to proceed – different knowledge transfer ⁄ application systems as it were. are we not altering our view of drug users. Hence. 1) not only questions the validity of the research Hwang is so confident in. Yet he also admits that ‘public polices arise through a complex process that is influenced not only by information and evidence such as that obtained by research. however. it is a construction of reality that we determine. Furthermore. with justification. but disagree on the research findings calling each other ideologues. that there is a consensus among health scientists concerning this position. that many of the same harms to individuals and society could be ameliorated if we managed to end drug use altogether. previously remarked. He then posits that ‘However. the recognition and promotion of stable rights that have been formalized and sanctioned – patient rights advocacy (Gaylord and Grace 1995). 62) calls critical responsiveness? ‘Critical respondents … enter into practices of self-modification in the very process of changing their recognition and treatment of the others already in motion’. 2007. legitimated. authoritative. a common world. different conception of what to do about it. of illicit drug use and that is certainly what it is to some extent. Take. a recent exchange regarding harm reduction in the electronic journal Open Medicine. agree on the importance of research. as both Latour and Connolly also attest. While on the one hand. in order to see them differently we. Rather. Thus. arguing about what to do with drug users. but also an ontology. funded and so on. In effect. I do not simply mean. but also that we work at modifying ourselves when confronted with us ⁄ them dichotomies. 62–3). Nor do I only refer to the facilitation of voice. Mangham 2007a). but essentially labels Hwang and those who agree with him ideologues: I would argue that harm reduction as ideology has and continues to interfere with the objectivity of researchers and civil servants alike … I have found repeatedly that harm reduction in Canada is itself an ideology and it is suppressing through self-selection the open dialogue. what they do. In a response to this article. Put simply. in the way that I have just described it. 6). However. for example. epistemology as it were? Isn’t it a form of what Connolly (1999. why they do it. must also become different. Moreover. that is us. might well be termed democratic advocacy. employed. that is ‘active work on our current identities in order to modify the terms of relations between us and them’ (Connolly 1999. 18) What we appear to have then are two experts. it is the proper course of action. moreover. the methodology and findings of harm reduction science also has its critics (Davies 2007. sanctioned. we are presented with different views of drug use. as I have Ó 2009 Blackwell Publishing Ltd However. To be sure that Pauly et al. which is to say – reality. who they are. and honest pursuit of truth that we need. exploration of meaning and self-determination – existential advocacy (Gadow 1980) thought both are important. knowledge does not predict its own action. on the other he labels those who disagree with the research ideologues. Hwang (2007) claims that the research on harm reduction suggests that it is a sound and effective approach to drug use (particularly supervised injection sites) and. it recognizes that politics is not merely an organization of society. 6). By this. are correct in that there is a substantial amount of evidence that harm reduction can indeed reduce the deleterious effect of drug use both for individuals and the society in which they live. it demands not only that we be accepting and tolerate. moreover I also agree that: patient advocacy is not merely the defence of infringements of patients’ rights. there are also those who claim. the health of the nation is placed in peril if our leaders ignore crucial research findings simply because they run contrary to a rigid policy agenda driven by ideology or fixed beliefs’ (p. Indeed the article is entitled ‘Science and ideology’. reality is a political assembly and furthermore politics is the act of constructing what is and is not accepted.

I offer Connolly (1995a. Rather I have attempted to outline a position. or ought to be. Nurses then need to advocate for a politics of becoming that is typified by ‘care for the plurivocity of being’ (Connolly 1999. I have challenged the typically held belief (though certainly not by everyone) that nursing is. Special acknowledgement is given to Dr Ploeg who read several early drafts of this manuscript and responded with important comments and criticism. I have endeavoured to shift the agenda of nursing from the unproblematic practice of knowledge application ⁄ transfer of postpositivist theory to the highly problematic conditions of radical democracy. 82): Nothing proves. modes of suffering. that reality is political. for Latour at any rate. can anticipate. legitimately. And moreover. Such democratic construction requires all voices. we can have all manner of discussions and debates about what evidence and knowledge mean and when. For postpositivists. or what might be termed postepistemological thought. I hasten to add that. as I have tried to demonstrate in this study. I do not of course consider my position incontestable or even fully articulated at this point. Hence rather than the politics of reality that characterizes the. science ⁄ culture wars. more bucolic. belief in stability. Finally. nicer. nor the importance of existential issues of advocacy. so-called. the development of new. predict and plan for (Smadu’s aforementioned view). that the participants are all going to find themselves in the ecumenical equivalent of some Woodstock festival in honour of Gaia … Let there be no misunderstanding: [postepistemology] is not going to be simpler. tion is something to be avoided. that is heretofore unimagined. types and so forth. critical of the radical thought that I have endeavoured to explicate. by a modernist use of things like knowledge. support and critical feedback during the development of these ideas. to the advocacy agenda of nurses in that it recognizes. In effect. a profound thanks to Andrea Smith-Betts for both editorial assistance and the critical discourse that comes with it. as Connolly suggests. and moreover holds great promise for nursing as a discipline. 1995b. research. 159).(Connolly 1999. Rather it adds. Thanks also to the Fall 2007 Philosophy of Science Nursing PhD class at the McMaster University for listening to a presentation of the ideas contained in this study and providing valuable feedback. or that knowledge transfer ⁄ applica270 Finally. For it is extremely probable that all of us today are unattuned to some modes of suffering and exclusion that will have become ethically important tomorrow as a political movement carries them across the threshold of cultural attentiveness and institutional redefinition. violence and anarchy today does not emerge from political engagement with the paradox of difference. founded upon a postpositivist epistemology. Ó 2009 Blackwell Publishing Ltd . efficiency. I do not claim that there is anything easy or simple about it. evidence. using Latour from philosophy of science and Connolly from democratic theory. and our naıve definition of knowledge as simply that which is ¨ unproblematically transferable. kinds. significantly I hope. or applicable to a situation. or impractical relativism. Moreover. science. Democratic advocacy does not deny the need for nurses to defend the rights of patients. our. From here. when and how to use them. ACKNOWLEDGEMENTS The author would like to express thanks to Drs Jenny Ploeg and Catharine Tompkins from the McMaster University School of Nursing for assistance. effectiveness and so forth. unity and endurance of identities. including the nonhuman’s scientists claim to speak for. CONCLUSIONS I have attempted in this study to situate nursing within an ontopolitical matrix of radical pluralism. circumvented if you will. Nor does it claim that practicing nurses do not need knowledge and skill. for those who might be. but also. knowledge is provisional yet at the same time relatively secure. however. It emerges from doctrines and movements that suppress it’. such an advocacy requires an understanding of change not only of the kind that we are aware of. while I do believe that the position I have attempted to outline and defend is a beneficial one. all too modern. Both Connolly and Latour also readily admit this. or ought to be.CE Betts finally. I admit that I have only introduced the concept here and much work is required to develop and refine it. knowledge is inherently political and hence. I end then with a slight paraphrase of Latour (2004. xxi) claim that: ‘The biggest impetus to fragmentation. more rustic. relational. constructed by (democratic) due process rather than short circuited. that the assembly is going to come off well. to be heard during the assembly of reality. I offer a reality of politics as the bases for nursing practice. from which to view nursing and nurses as democratic advocates. reality is. in that it tends to fragment into an unworkable. designations. than the old … politics. whereas for the postepistemologist. 68) Suffering that is or might often be the result of. which has as its central aim the critical responsiveness to human suffering.

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