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Displacement of Agency : The Enactment of Patients' Agency in and beyond Haemodialysis Practices
Wen-yuan Lin Science Technology Human Values 2013 38: 421 originally published online 3 May 2012 DOI: 10.1177/0162243912443717 The online version of this article can be found at: http://sth.sagepub.com/content/38/3/421

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Science, Technology, & Human Values 38(3) 421-443 The Author(s) 2012 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0162243912443717 sthv.sagepub.com

Displacement of Agency: The Enactment of Patients Agency in and beyond Haemodialysis Practices
Wen-yuan Lin1

Abstract How might the agency of the subaltern be conceptualized within the intersection of multiple worlds? Actor-network theorys (ANT) translation framework for understanding agency portraying this as entrepreneur and talking of a world in the making is arguably imperialist, managerial, and monolithic. Draws from the enactment turn of ANT and insights into the politics of representation, this article elaborates an alternative framework which focuses on displacement. By examining the case of dialysis patients, the article explores the displacing practices that follow the disruption of routines in dialysis. Patients have to go through a process of problematization, distribution, hybridization, and restabilization, in order to sustain the coexistence of their alternative practices with dialysis. Unlike
1

National Tsing-hua University, Hsin-chu, Taiwan, Republic of China

Corresponding Author: Wen-yuan Lin, National Tsing-hua University, No. 101, Sec.2, Kuang-fu Rd. Hsin-chu, 30013, Taiwan, Republic of China. Email: wylin1@mx.nthu.edu.tw

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entrepreneurs in the translation model who transform the world by interesting others, enduring trials, and becoming spokespersons for all, those patients who manage to displace and sustain the coexistence of multiple worlds avoid interesting, still less confronting, the hegemonic actors and claiming representation for themselves. This article suggests the displacement of agency as a generic alternative. Keywords actor-network theory, agency, representation, patient, subaltern

Introduction
How might the agency of the subaltern be conceptualized within the intersection of multiple worlds? Actor network theorys (ANT) translation framework treats agency as the effect of a series of processes which include problematizing, interessment, enrollment, mobilization, and representation (becoming a spokes-person; Callon 1986). More recently, ANT has become more aware of the complexity and multiplicity of practice (Law and Hassard 1999; Gad and Jensen 2010). Nevertheless, in its original version it was accused of being imperialist, managerial, monolithic, and unduly dependent on models of entrepreneurial agency (Star 1991; Fujimura 1992; Lee and Brown 1994). As a part of this, it was argued that the experiences of marginalized actors struggling in and between already-made networks do not fit the standard ANT scenarios, and their agency does not find a place in the trope of the trial (Mort 2002; Star 1991; Singleton and Michael 1993). This article draws from the enactment turn of ANT and insights into the politics of representation, to develop an alternative conceptualization of agency. It explores the ways in which dialysis patients in a particular context in Taiwan manage the intersections between practices of biomedical and alternative medicine. It does this by considering what happens when dialysis routines are disrupted. Initially, such disruption renders the agency of patients indeterminate. Subsequently, patients go through a process of problematization, distribution, hybridization, and restabilization as they restore their agency by mixing alternative therapies with dialysis practices. But this process reveals that patients work by displacing their problems rather than translating them. In particular, it reveals that this process of displacement makes it possible to combine dialysis with alternative therapies.

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The article thus proposes that displacement should be understood as an alternative to translation. In the translation model, action takes many forms, but most attention has been paid to agonistic agency. The exemplary case comes from science in action: when a scientific object successfully endures trials, a contested statement is black boxed into an established fact/truth, and the scientific entrepreneur makes himself or herself the spokesperson for the truth (Latour 1987). Despite challenges, this original formulation of agency remains substantially intact in much writing influenced by ANT (Akrich, Callon, Latour 2002a, 2002b; Latour 2005, 43-62). This displacement model challenges thisand the politics of representation by drawing from Gayatri Spivaks (1988) concern with subaltern representation. Spivak distinguishes between representation as delegation (vertreten) and representation as re-presentation (darstellen) in imperialist and nativist empirical accounts of Hindu widow immolation. She argues that this conflation (a false understanding of the world as representation-darstellen) effaces representation-vertreten and renders the oppressed as the inaccessible Other. However, as ANT reminds us that representation is more than textual or discursive practice, and reality is done in interconnected local materialsemiotic enactments by heterogeneous participants, including patients (Law 2004, chap. 2). The ways in which patients devise tactics to prevent confrontation with medical personnel suggests that displacement represents an important form of subaltern agency.

Enacting Agency
The enactment approach adopted by actor network theory implies a practical ontology; rather than treating reality as something that is constructed by substantial and pregiven actors, it treats this as an effect of sustained enactments or performances (Lin 2007; Jensen 2010, 7). As Annemarie Mol notes, ontologies are brought into being, sustained, or allowed to wither away in common, day to day, sociomaterial practices (2002, 6). Extending this approach to biomedicine brings out a new understanding of medical settings: the development of heterogeneous things in the making of biomedical reality (Jensen 2010). The enactment approach opens up a world in which diseases, patients, protocols, medical personnel, medical records, examination, techniques, instruments, treatments, laboratories, and organizations all play their part in the making of the sociomedical world (Berg and Mol 1997, 1998; Prout 1996; Van der Pleog 1995; Law and Singleton 2003; Jensen 2005).

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As a part of this, enactment approaches make no assumptions about the character of agency but seek instead to explore how this is constituted in multiple sites of practice (Law 2004). Studies of how wheelchair users put themselves in different settings in making spatial passages and of how people suffering from spinal muscular atrophy and diabetes using orthodox medicine and alternative therapy and measuring blood sugar and feeling the body, show that they are able to configure and maintain different modes of agency (Mol and Law 2004; Moser and Law 1999; Callon and Rabeharisoa 2004). This tells us that while managing their bodies, selves, and diseases, patients participate in the enactment of particular ways of being in which their agency unfolds. Mols (2002) ethnography shows that there is not one, but rather multiple versions of atherosclerosis. The disease is variously enacted in different and situated practices in daily life, the clinic, the pathology laboratory, and the operating theater. Cussins (1996) explores the dynamic unfolding of agency in in vitro fertilization practices. While women are still in active treatment, medical procedures are seen to fit with agency. If treatment fails, the women talk of feeling alienated or dehumanized. These inconsistent accounts suggest that the subject participates and that understanding of ones own agency rests in the unfolding of the uncertain trajectorieswhat Thompson calls an ontological choreography of womens agency. The final move is to realize the enactment potential for understanding the contingent unfolding of agency in the intersection of multiple worlds. The body multiple and ontological choreography are made within and between the contesting enactments of an established world, resting in the hospital and in forms of treatment that are mainly organized in terms of a biomedical regime. What happens to their agency when patients attempt to act in ways that are radically different, such as traditional Chinese medicine and spiritual therapies? Tackling how Chinese medicine or forms of spiritual therapies interfere with biomedicine might seem a large topic for a single paper. The strategies of translation, mapping, temporalizing, and repositioning of traditional Chinese medicine in the encounter with hegemonic biomedicine in the contemporary China and worldwide have been widely discussed (Lei 1999; Barnes 2003; Scheid 2002; Kim 2007; Zhan 2009). Yet the specificity of patients involvement and the constitution of their agency in the intersection is exactly the focus of this article. The argument is empirical, and this is because large systems only ever relate together in specific empirical practices including those in which patients manage their medical condition.

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Accordingly, I focus on a serious specificity: what happens after the failure to insert the needle into the fistula1 in hemodialysis, without which patients can no longer use dialysis to sustain their lives. The cases are taken from fieldwork notes and interviews from a period of participatory observation in a dialysis clinic in Taiwan, a country where alternative medicine is popular. Names and places are anonymized.

Problematization
Patients with end stage renal failure disease (ESRD) rely on regular dialysis, a standard therapy in biomedicine, to sustain their lives. This is normally done three times a week. A fistula is literally a patients lifeline, because a well-functioning fistula is essential for the successful insertion of a needle to drain out sufficient blood for dialysis. The whole biomedical deployment of a dialysis clinic relies on this lifeline to connect patients and enacts patients as capable of dialysis. Therefore the failure to insert a needle is a short but nonetheless critical moment for a patient.
Mr. Lee lies on the bed looking at his left forearm. A nurse, Ms. Chiu, is holding a needle in her right hand and using the index finger of her left hand to feel around Mr. Lees fistula. Another nurse, Ms. Hsu, is helping Ms. Chiu; her right hand is pressing a cotton ball onto the other end of Mr. Lees fistula. Occasionally she interrupts Ms. Chiu by touching Mr. Lees fistula and making suggestions about where it might be better to insert the needle. Mr. Lee and the nurses look worried. This is the second attempt. In the first, the needle went in but no blood came out. After a few adjustments, blood appeared but Ms. Chiu thought that the flow was not strong enough. Therefore, the needle was pulled out. After asking Ms. Hsu come to help, they were preparing for another try.

How was the agency of the patient transformed in these fistula-related practices? Patients do not normally worry about their ability to acttheir agencyto sustain their dialysis. Dialysis is a standardized therapy for medical personnel and a routine treatment for patients. Extending Laws (2004, 131-34) insight, the possibility and ability of a patient to do dialysis is an effect enacted in dialysis method assemblages composed of knowledge, machines, medical professionals, medical records, a fistula, and blood, and so on. If everything had proceeded according to plan, the well-stabilized routine and the agency deployed as a part of this would not have changed, and

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the issue of the agency of the patient would not have been raised. However, the first attempt to insert the needle had failed. The flow of practices mediating Mr. Lees agency to do dialysis was stopped, and the assemblage of his agency were no longer taken for granted. The failure to insert might mean nothing or it might be a disaster; at best it was due to the poor technique of Ms. Chiu, while at worse it meant the fistula had shrunk and Mr. Lee would need to have a painful dilatation operation to expand the fistula or even worse to have another fistula rebuilt. This makes it one of the moments when patients are scared; sometimes described by patients as the end of the world for it could be that they cannot do dialysis anymore. Despite the potential for severe consequences, at this moment Mr. Lee could do nothing but wait. Ms. Chiu was searching for a better part of the fistula for another attempt to reenact the dialysis deployment. If it worked, then it might have nothing to do with the fistula. But until then the problem would remain undecided and the configuration of Mr. Lees agency in dialysis would remain indeterminate.

Distribution: Displace the Problem out of the Clinic


But indeterminacy is usually resolved. Let us return to the scene.
The second try succeeds. When things are settled Ms. Chiu disconnects the tube and the syringe attached to the needle and puts on another tube and syringe. The blood in the used syringe and tube is diluted by saline solution in the syringe and turns light red, but there are some dark red tissues floating in the solution. Ms. Chiu shows the syringe to Mr. Lee and says: Sorry about that. But your fistula is really not good. There are clotting tissues in the blood coming out of the fistula. See, here. Do you hot compress your fistula the day after dialysis? Your fistula is so hard. . . . Mr. Lee does not say anything but glances at the syringe. Ms. Hsu follows, Yeah, it is so hard. You dont hot compress, do you? Mr. Lee twitches his mouth and reluctantly says, I dont have the time. Then he keeps looking at his fistula and occasionally touches it with his left hand. Ms. Chiu then gives Mr. Lee a few sheets of paper which describe how to exercise and hot compress, reminds him to ask the doctor to prescribe some medication, and advises him to consult a surgeon if his fistula needs a dilation operation.

Dialysis had to carry on and at the same time the question of agency was moved forward and configured. To do so, Ms. Chiu and other actors had

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to do a great deal. Ms. Chiu changed the syringe, apologized, and she also showed the clotted tissues and told Mr. Lee what had caused the clotting. By going through the causal relations of the problem, Ms. Chiu reenacted the failed configuration of Mr. Lees agency. Here Ms. Chiu represented the problem; she distributed the failure to Mr. Lees daily self-care, rather than, say, her skill. But Ms. Chius practices alone could not complete this distribution unless other actors did their work: the clotted tissue and the hardened fistula were turned into forms of demonstration, and even Mr. Lee participated in the enactment and remembered what went wrong. But the representation did more than this local enactment. John Law suggests that representation is:
[T]he enactment of a bundle of ramifying relations that shapes, mediates and separates representations in-here, represented realities out-there, and invisible out-there relations, process and contexts necessary to in-here. (2004, 84)

So what is happening to agency here? The configuration of Mr. Lees agency seemed to be narrowed down to the fistula but was actually expanded to Mr. Lees daily life. Mr. Lees inability to do dialysis was fused with the facts of seeing the clotting, feeling the hard fistula, remembering that he had neglected his fistula, and reflecting on his lifestyle that was too busy to allow him to hot compress. The breakdown of the routine configuration of agency that achieves dialysis was distributed to the lack of other forms of patient agency, such as performing daily care. Moreover, the biomechanical mechanism of and solution to a clotting fistula were also enacted in the animal experiments of laboratories, compared, discussed, and validated in the clinical reports in journals, authorized in the narratives of textbooks, and taught and practiced in the training of dialysis personnel. They were done in a wide range of locations within biomedicine. Thus, this episode distributed the problem to the fistula and Mr. Lees daily practices, and configured Mr. Lees agency by resonating with the enactments of a biomechanical body in biomedicine. But there are different distributions and configurations. Mr. Chen and Mrs. Lai had similar problems but they had a different plan. Mr. Chen told me:
I believed in western medicine before as you do. At that time I took so many medication prescribed by doctors but I was weak. Sometimes I came to dialysis on a wheelchair. . . . Then a miracle happened. Since I followed the Sacred Mother, I am getting better and better.

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I asked what happened and who the Sacred Mother was. He replied: Sacred Mother is embodied by the Avalokitesvara. In her temple, she offers holy water that cures lots of people. While drinking the water, you have to chant a religious script sincerely a couple of times . . . . She also uses a rod to beat you on the back to reduce the sin handed down to you from previous lives. Our bad temper, bad luck, and disease are caused by these sins. . . . She also teaches us san ji shi (good knowledge), it is about how to follow the heavenly gods principle of treating people well, serving your parents, and doing good. Following good knowledge, we not only do not accumulate sin, but also reduce those from previous lives, we save our sacred heart. . . I asked him how this helps him. Mr. Chen says: Quite a lot. Last time my fistula was clotting, the medication was useless and I was told I needed a surgery. . . . My uncle who was saved by the Sacred Mother in a car accident took me there. On the first visit, I was reluctant and he forced me to try the water. Magically, my fistula got better afterwards. Then I went again and again by myself, and asked for more help sincerely. I also do my best to do good, and spread good knowledge in daily life. See, I didnt have the surgery, but my fistula got better . . . Now I go there regularly. . . . Thanks to the Sacred Mother, I am much stronger and now I work in my uncles furniture factory. Can you believe it? I can carry a shelf that is two meters high to the fifth floor on my feet!

Mrs. Lai was new to dialysis because of her diabetes. She usually needed to have excess fluid removed in a dialysis session and ended up with low blood pressure. After a few months, she often had failed insertions. According to the nurses, a fistula clots easily when there is prolonged low blood pressure. Apart from hot compressing, nurses also suggested that she should not drink too much. But that did not work. Mrs. Lai was worried, at first she complained: I barely drink water but still retain lots of water in my body. Six months later I interviewed her while she was having dialysis. Everything was fine. She told me:
I visited a very good Chinese medical doctor recently. In the last few years, I had visited so many different doctors, even some ridiculous alternative therapists, but none could do anything about my diabetes, and I ended up on dialysis. But this one is very good. . . . He is good at palpating. In the first visit, simply by palpating, he told me that the problem was my phlegmdampness somatotype. The obstinate phlegm-dampness weakened the spleen meridian that governed the circulation of blood, which furthered weakened the lung meridian that governed the circulation of water. . . . He prescribed herbs for one month and powdered medication afterwards, and wanted me eat

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more almond and Chinese yam that were good for the circulation of chi (vital energy flow) in the lung and spleen meridians. Since then I do not retain so much water anymore. When I asked her more specifically about the fistula, she said: I asked the doctor do I need to have a dilation before the fistula shrank. He told me that the surgery was a downstream solution, and my problem was first about the phlegm-dampness. It weakened the spleen meridian that couldnt produce good quality of blood and circulate it well. The situation got worse, and my lung meridian was weakened and couldnt circulate water properly. So I retained water. If we did not solve the upstream problem I would need to have the operation again and again, for the blood was still sticky and my body still retained water.

Dialysis requires patients to follow biomedical practices in the clinic and other parts of their lives. However, because of patients lifestyles, habits, working conditions, family and religious backgrounds, and financial status, and so on, patients try to solve their problems using biomedical and alternative medicine at the same time. Therefore, patients sometimes find other way of arranging their agency. To tackle a similar fistula problem, Mr. Chen and Mrs. Lai took part in enactments of alternative causalities, solutions, and configurations. In the case of Mr. Chen, the practices linked the fistula problem to the relationships between the sacred heart, the accumulation and reduction of sin, and the embodied consequence of being a sinner. They related the solution to practicing good knowledge in daily life and therapies in the temple. And they configured Mr. Chens agency in the enactments of a spiritual body in a particular religious form of medicine. In the case of Mrs. Lai, what was enacted distributed the problem to the relationships between the phlegmdampness somatotype, the interaction between the meridians, and the circulation of chi and blood; the solution to taking herbal and powdered medicine and eating chi-enhancing food; and the configuration of Mrs. Lais agency, to the enactments of a chi body in traditional Chinese medicine.

Hybridization: Displace the Alternative Therapies into a Clinic


The alternative configuration of patients agency is not simple. While dialysis is practiced in a well-regulated clinic, alternative medicine is less integrated. Patients have to find ways through the various sites for themselves in order to do alternative therapies. This implies that instead of

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following the established dialysis deployment, patients have to go through, and sometimes organize, contingent and hybridized trajectories. For example, Mrs. Lais journey in Chinese medicine is more than shopping for a doctor. She also mentioned that when she took herbal medicine for the first time, she tried many Chinese medical pharmacies in order to buy better herbs, learned what kind of stewpot is better for stewing the herbs, learned how to stew, and coordinated her daily working life with the stewing and dinking of herbal soup, and so on. In order to generate an alternative version of agency, Mrs. Lai needs to go through a contingent trajectory, to hybridize the practices of various sites, and build herself an alternative medical world. More importantly, patients like Mr. Chen and Mrs. Lai were not only using alternative medicine in a temple and a Chinese medical clinic but also receiving dialysis; they sometimes brought these practices into the dialysis clinic. Despite the fact that dialysis professionals were opposed to these alternative therapies, there were rarely confrontations between the patients and medical personnel, and only occasional disturbancesa function of how well they collectively manage the contingencies. This is illustrated in the following.
Mr. Lee gives Ms. Chiu a report from the surgeon he visited, says: the doctor said my fistula was ok. No operation was needed now. Hot compressing would do. Ms. Chiu receives the report and replies: but do you hot compress? Mr. Lee nods. Sure, more than that I bought an infra-red heater I used in the clinic. Before the examination they had me radiated for thirty minute on the fistula. I felt that the blood flowed stronger. When leaving, I saw an advertisement saying that it could be used for daily care. So I bought one. Now, I either hot compress or radiate every day. . . . Is it safe? Ms. Chiu asks. Mr. Lee replies: sure, its manual includes licenses and reports. I will show you next time . . . . Then they discuss his medication, Mr. Lee adds: Im taking fish oil recommended by a patient in the waiting room of the surgery. Ms. Chiu does not trust in the fish oil. She asks him to stop taking it until she has had a chance to check it out. A few days later, Mr. Lee brings the manual and a bottle of fish oil capsules. Ms. Chiu and doctors are satisfied for the fish oil is approved by some EU authority and the irradiation instruments clinical trials are published in prestigious nephrological journals, and it is approved for clinical use by Taiwanese Ministry of Health. The doctors are quite interested in the instrument.

Mr. Lee did much more than simply following Ms. Chius instruction. He brought in the enactments from other sites; he was heating and hot

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compressing his fistula and taking medication with functional food at the same time. It was debatable whether these alternatives belong to the dialysis networks, as both were approved by authorities allied to biomedicine; nevertheless it is clear that the new practices slightly changed the configuration of Mr. Lees agency. The degree of change depended on how well the foreign enactments were articulated. As a matter of fact, after consulting their colleagues in Taiwanese Nephrological Society, the doctors acquired two heaters for the clinic and from then on patients were advised to use these during dialysis. In this instance, the contingent hybridization of a patient was easily articulated with the local dialysis enactments. Here the patients passage through the moment of hybridization was surprisingly smooth, but this was not always the case. Mrs. Lai found it slightly difficult. Let us go back to her interview.
After explaining her condition to me, Mrs. Lai turns to a nurse nearby and asks how much water has been drained. The nurse reads from the machine, says: two kilos already and half a kilo to go. Mrs. Lai thinks for a bit and replies: no, not so much, only 0.2 (kilogram) more. I told Ms. Wang that I dont want so much to be drained out. Let me check. The nurse checks Mrs. Lais medical record against the display on the machine, and says: your target dry weight is 55 and today you weighed 57.5, including the meal you had. It is 2.5. You dont want so much to be drained? Are you feeling your blood pressure is down again? Lets have a look. Mrs. Lai says she is fine and just does not want to be so dry. The nurse takes Mrs. Lais blood pressure and says: 130 over 78, it is good. OK. Ill reduce the amount I drain, but next time you should discuss with the doctors if you want to change the target weight. When the dialysis session finished Mrs. Lai decides to discuss this with the doctor on duty, but she does not go immediately. She turns her back to the nurses, drinks some water, and swallows a small pack of brown powder. When she asks the doctor to increase the dry weight, the doctor asks: do you feel too dry, any cramp, or low blood pressure after dialysis? Mrs. Lai says: Nothing. My Chinese medical doctor wants me do so. Why? asks the doctor. Mrs. Lai says: He thinks that my lung meridian is weakened partly by the drainage of water on dialysis. So I think I should try. . . . I see. The doctor interrupts while scanning Mrs. Lais medical record. Obviously he does not follow her. He continues: Mm, your chest X-ray taken three months ago shows that you heart lung ratio is good. Ok, increasing a little doesnt matter. I will change the order. Be careful with Chinese medicine, if you have any questions, please discuss these with us. . . .

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On our way out of the doctors office Mrs. Lai tells me that she does not think the doctor was listening to her: but this doctor is ok, so I told him what I was doing and I had my way. This helps my lung meridian. Being drained completely dry makes it idle and means that it loses function. . . . I ask why she turned around to take the powder. She says: I turned my back, because some nurses are annoying. They think Chinese medicine is harmful; they always say some people take poisonous Chinese medicine and end up on dialysis. . . . I dont blame them. I agree that not all Chinese medical doctors are capable and people abuse Chinese medicine. Mine is pretty good, he can understand the blood examination report too. I always bring my monthly report to him. . . . So I have to cheat sometimes. They have their rules, but I have my tactics. For example, my Chinese medical doctor wants me do dialysis at a higher temperature to improve my phlegm-dampness, but nurses are reluctant to do so. When I first asked they said that a lower temperature keeps you blood pressure up. . . . So I learnt and told them that I was cold . . . They bought it and increased the temperature. It saves trouble.

Unlike Mr. Lee, in order to follow her alternative therapy Mrs. Lai had to use tactics. Mrs. Lais practices interfered with essential parts of dialysis including setting the patients target dry weight and temperature of dialysis, all done in a setting including machines, a process of clinical treatment, calculations in medical records, and regular monitoring including hourly blood pressure and six-monthly x-rays. Tactics were necessary, because Mrs. Lai was mixing incompatible Chinese medicine with biomedicine, and enactments of chi with biomechanical bodies; more correctly, she was introducing subaltern Chinese medicine into a dialysis clinic, one of the strongholds of hegemonic biomedicine. Despite the challenges, Mrs. Lai had done so not by provoking, but by negotiating with, lying to, and hiding what she was doing from medical personnel. For instance, when she turned her back and complained being cold, she quietly built herself a Chinese medical world in the biomedical clinic. This was how and where she bypassed the incompatibility, and hybridized therapies, not permanently and comprehensively but temporarily and locally. This scenario further reveals the specificity of subaltern agency in contrast with that of entrepreneurial agency. An entrepreneur hybridizes and translates the heterogeneous agency of others in order to raise the world and innovate (Latour 1983; Akrich, Callon, Latour 2002a, 2002b). But subaltern agency manages hybridized coexistence precisely without interesting others. The subaltern does not want to rearticulate the incompatibility

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or challenge biomedicine; neither was of concern to Mrs. Lais, and they were in any case way beyond her capability. What she wanted was both dialysis and phlegm-dampness. Moreover, unlike an entrepreneur who wants to interest others in order to have them do things for him or her, Mrs. Lai learned from experience that it was futile to inform the annoying nurses (though she still tried to explain to the ok doctor). Overall, however, she normally avoided interesting medical personnel and kept herself unnoticed so as to find ways to have the dialysis establishment do things for her. Take changing the temperature setup for example. In standard dialysis practices, lowering the temperature shrinks a patients blood vessels and prevents blood pressure from falling. However, in Chinese medicine, increasing the temperature facilitates the circulation of chi and blood in the body, and eases the deteriorating phlegm-dampness somatotype. The contradictions were bypassed, as Mrs. Lai did not ask for a higher temperature by saying that my Chinese medical doctor says that this is needed, and enacting herself a follower of Chinese medicine who was challenging biomedicine or at least disturbing routine practices. Instead, she lied and said, I am cold. By doing so, the situation, the nurses, and even the dialysis machine were all displaced and hybridized together: the potentially antagonistic situation was rendered routine, the nurses following biomedical stipulations enacted Chinese medical practices, and a dialysis machine that was supposed to warm up a biomechanical body facilitated the circulation of chi. Displacing and hybridizing alternative practices without being noticed, this illustrates just one of the tactics subalterns employ to enact alternative agency in the intersection between the hegemonic and the subordinate.

Restabilization: Displace the Trope of Trial and the Situation


The failure of a fistula rendered the agency of dialysis patients indeterminate, and problematization, distribution, and hybridization followed. But as we have just seen, unlike entrepreneurs, patients did not challenge the biomedical world but managed to sustain their alternative subaltern world alongside or within one that was hegemonic. This process was a medical as well as an ontological passage through which patients brought their particular ways of doing dialysis, and hence configurations of agency, into existence. Some, like Mr. Lee, might find it easier to follow enactments allied with biomedicine, but others such as Mrs. Lai discovered that their alternatives were not compatible with the configurations of dialysis.

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Depending on how well they managed to resist the challenges of biomedicine, the alternative agency of such patients might or might not be sustained. This highlights the last but probably the most critical moment in the process of restabilization. The stabilization of agency is essential in the translation model and is achieved in trials of strength:
[D]epending on the trials of strength, spokespersons are turned into subjective individuals or into objective representatives. Being objective means that no matter how great the efforts of the disbeliever to sever the links between you and what you speak for, the links resist. Being subjective means that when you talk in the name of people or things, the listener understand that you represent only yourself. (Latour 1987, 78)

This model is still present in Latours more recent writing:


Without accounts, without trials, without differences, without transformation in some state of affairs, there is no meaningful argument to be made about a given agency. (Latour 2005, 53)

However, patients find it difficult and unwise to draw attention to their alternatives, and certainly do not want to push matters to a trial. In practice, as we know from Mrs. Lais case, patients avoid a head-on confrontation. Callon and Rabeharisoa (2004) have reported a similar tension in the case of a patient who refused to engage with a medical network and a sociological interview as he enacted his agency. This highlights the specificity of entrepreneur agency in the translation model. Enduring trials in order to decide the spokesperson may be important in science or innovation (Latour 1983, 1987; Akrich, Callon, Latour 2002a, 2002b). However, in medical practices such as dialysis, the main preoccupation of all concerned may not be putting each other on trial, but to keep the routines and the lives of the patients going (Berg and Mol 1998). Though clinical situations change from time to time, trials are unusual. But the tension is always there, and occasionally when a patient determines to speak for himself or herself the peace is disturbed. This was what Mr. Chen taught us. Unlike most patients concealing their alternative therapies, Mr. Chen was so eager to spread the good news about helpful religious therapies that he edited a pamphlet about his way of dealing with dialysis related problems and distributed it widely among patients.

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Mr. Chen also relentlessly put his ideas into practice. Here is one occasion I witnessed.
I am interviewing Mr. Chen in the clinic. Recently, Mr. Chen has reduced his frequency of dialysis from three times a week to five times a fortnight, then to twice a week. The nurses are angry and worried, but Mr. Chen insists that this is right. The nurses know that I am interviewing him and we are getting on well. They ask me to persuade him to change his mind. When I mention it, Mr. Chen says, I am not doing this blindly . . . . I am trying very hard to achieve this. My parents gave me my body, and I should not hurt myself. I carefully evaluate the condition and try to transfer from dialysis to other ways of doing things gradually. According to him, such therapies and dialysis are like cars. Living a life in the world is like taking a ride in different cars. Doing dialysis is riding one kind of car and other therapies are others. . . . What is important is that we know where we are going and are not being confined to the car in which we are travelling. . . . If we can make the body more accustomed to other cars, then we wont need dialysis. He does not think very much of biomedicine, because Its development is based on the sacrifice of other lives, it disturbs the harmony between nature and the body, and all of these chemical medicines are poisonous . . . basically, it is not compatible with the principles of good knowledge. Since his ultimate goal is to follow good knowledge in order to improve his sacred heart, while dialysis works for his body he has to find therapies that he can drive that do not contradict good knowledge. He is very confident and proud of his achievement. When we are talking, Ms. Hsu walks by. She stops and listens to us for a while. Then she interrupts and talks to Mr. Chen: How many sessions are you doing next week? Mr. Chen replies, Two. I have told the deputy nurses. Ms. Hsu says, Two! You are risking your life! Your monthly blood examination report is here . . . . She searches and takes out a paper from the pile of papers she is holding and continues: See, your uremic level is high and the potassium and other ion levels are high as well, but others, Hb, Hct, protein levels are low. You are not having sufficient dialysis and you are very weak. Eat some meat, vegetables are not enough . . . I will arrange three sessions for you, all right? Mr. Chen smiles, he says, No, thanks, I am fine. I feel energetic . . . and everything is going well. I think I only need two. Ms. Hsu says: I wont argue with you any more . . . so long as you take good care of yourself. Then she turns to me, shakes her head and says: He is so stubborn, and leaves. Mr. Chen then tells me: You see. Western medicine is obsessed with trivial things, and doesnt care about the fundamental things. How can you say that I am not well just by looking at the biochemical test, when I am so energetic

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and able to do more work? My experience and abilities compared to test results, which do you think is more important and credible?

This was a very unusual event. At this moment, different configurations of agency were challenging each other; each tried to restabilize itself by problematizing the other. From Mr. Chens perspective, the indicator of his agency was not a blood examination but rather the fundamental daily experiences of feeling energetic and sensing that everything was going well. In order to keep his fistula, and even better his health and sacred heart, well, what he should enact was not keeping the dialysis schedule or eating more protein but practicing good knowledge. There seems to have been a trial about the sustainability of the reality of the sacred heart and Mr. Chens agency going on. The point had been that when other people had said that everybody had known that biomedical dialysis was the right thing to do and religious therapies were superstitious, they had had to make the point. The nurse had done so; she had shown Mr. Chen his blood test results. This simple action had drawn in widely institutionalized networks of biomedical practices. In contrast, without scientific institutions behind him, Mr. Chen also had enacted networks of religious or traditional practices shared by many people by introducing his experiences in conversations and in his pamphlet. However, this would have been an unfair trial, not only because Mr. Chen would have been alone when he was facing the wide institutionalized biomedicine but also because a biomedical configuration of agency had been routinely and collectively enacted in the clinic, whereas Mr. Chens version of reality had only been temporarily enacted in his presence through the pamphlet. It would have been unfair that most witnesses, patients in this case, had enacted an asymmetry between questionable superstition on one hand and justifiable, biomechanical biomedicine on the other. This episode continued and ended a few months later.
When I arrive at the clinic, Ms. Chiu tells me silently: Do you know that Mr. Chen passed away? He was outrageous. He has only six dialysis sessions last month. . . ! I was shocked and grieved over Mr. Chens failure to prove himself. When the news spread patients and nurses talked about Mr. Chens early death. They say, he shouldnt have done dialysis that way . . . , he was so superstitious. . . , I knew that he was risking his life. . . . Mr. Lee and Mrs. Lai both agree with this.

Was this a moment of truth that revealed the result of the trial about Mr. Chens agency? Now, the nurse was the one still speaking. According

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to the translation model, the trial had turned Mr. Chen into a subjective representative of an unsustainable therapy and Ms. Chiu into a spokesperson of objective biomedicine. But, as I have suggested above, there is another way of reading this. It can be understood as an example of the epistemic violence of hegemonic biomedicine and the politics of representation in conceptualizing agency. Donna Haraway has warned us that the agonistic scenario of a trial reflects a winners world view, and says:
The story told is told by the same story. The object studied and the method of study mime each other. The analyst and the analysand all do the same thing, and the reader is sucked into the same game. (1997, 34)

The story of Mr. Chens irrational superstition told by the biomedical personnel and Mr. Chens unaccountable agency retold in an account that treats this as a trial further exemplify agency, precisely as the outcome of a trail. But what if this is not the only thing going on? What can we see if we do not follow the representations of the medical personnel? What other modes of agency are available? The trope of the trial portrays a world on the model of an amphitheater where ambitious combatants fight each other until the last man/woman stands. It enacts a particular situation with dualistic moral statuses, winner/loser and subject/object, for the participants. Perhaps, this is the case for science (though there is work that suggests otherwise), but it is certainly not what happens in clinical treatment (Mol 2002). So how might we think of this? Haraway talks of diffraction. She suggests:
Diffraction does not produce the same displaced, as reflection and refraction do. Diffraction is a mapping of interference. . . . A diffraction pattern does not map where differences appear, but where the effects of the differences appear. (1992, 301)

Paraphrasing Haraway, this diffraction of patients agency does not end up with an objective world of a winner left standing among the losers. Instead, knowledge is situated: a world must always be articulated, from a particular point of view (1992, 314). What is this situation from the patients point of view? Certainly, biomedical truth is sometimes enacted in clinical treatment; in the practice of finding out what went wrong; and in describing problems and explaining examination report to patients. While pursuing this objective truth, as Latour suggests (1993), complex agencies are first hybridized and then purified in order to be verified independently in

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carefully coordinated situations of trial, and then a specific, purified version of agency is enacted as if it were pure from the very beginning. However, patients do not necessarily care about truth/fact (Mol 2008, 42-65). For instance, those pursuing alternative therapies care more about sustainability; when their fistulas, bodies, or something else goes wrong, biomedicine has only unsatisfactory solutions. Whether it is a functional supplement, Chinese medicine, or spiritual therapies, patients are forced to search for various alternatives that have proven to be useful but do not necessarily comply with biomedical truth. Therefore, to understand these patients agency, we need multiple visions, exploring both biomedical representation of evidence and facts, and patients alternative enactments which are hiding away from, underrepresented or unrepresentable in biomedicine but are essential in supporting patients accounts of themselves and their lives. Thus Thompson writes:
agency here refers to actions that are articulated to people or claimed for oneself, that have definitions and attributions that make up the moral fabric of peoples lives, and have locally plausible and enforceable networks of accountability assigned to them. (2005, 181, italic original)

So, what happened to the configurations of agencies in the revelation of Mr. Chens death? First of all, it was about Mr. Chen. Ms. Chiu was reenacting Mr. Chens agency. Ms. Chiu represented Mr. Chens practices as outrageous and reminded patients that alternative practices were potentially lethal; Mr. Chens alternative practices were reenacted as the disabling enactment of biomedical agency, hence contributing to the loss of Mr. Chens agency. Second, it was about biomedicine. As they normally do, dialysis personnel enacted what had happened in a specific way in order to demonstrate the superiority of biomedicine over alternative therapies. This repaired the disrupted routine and resumed the disturbed biomedical configuration of agency. Thirdly, it was about the other patients. If biomedicine reclaimed its hegemony over alternative therapies in such a dramatic situation, some patients might follow the warning and gave up their alternative therapies, while others, like Mr. Lai when being warned about Chinese medicine, would not confront the dialysis personnel but simply concealed their practices more carefully. In this sense, patients were rendered compliant, continued to dissimulate, and were only rarely assertive. Their counterparts, the nurses, and doctors were alternatively helpful, annoying, or ok most of the time, but also

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proactive in the context of such a dramatic event. Taken together they were enacting many different configurations of agency, since the changing situations rarely ended up as trials, and there are much more than winners or losers in the dynamics of moral status. Such was the enactment of subaltern agency in the unfolding displacements. Finally, in addition to changing ANTs account of subaltern agency, this displacement interpretation provides alternatives to Spivaks theoretical skepticism about the inaccessibility of subaltern agency. To think of subaltern agency as displacement is to align with Spivaks argument. But there is a major difference too. Spivak suggests that the subaltern cannot speak; the hegemonic representations speak for the oppressed and render her as the inaccessible Other. Thus, though the position of noncompliant patients is very different from that of Hindu widows, both are subordinated by hegemonic representations that speak for them: for widows, there are Western intellectuals, nationalists, and imperialists; and for patients, there are professional power, the cultural imperialism of biomedicine over Chinese medicine, and the domination of biomechanical over chi and spiritual understandings of the body. However, instead of assuming the subaltern wants to speak and wondering whether the subaltern can speak against the hegemonic, what this article has shown is that patients displace their problems rather than speaking for these, the therapies, themselves, or the situations they find themselves in. The elusive, unrepresentable subaltern silence should not be understood as a failure. Rather, it counts as a remarkable achievement. What are the implications of recognizing this silence as an achievement? Does not being silent simply help sustain the status quo of hegemonic practices? Can displacement as agency make any difference to the position of the subaltern? Unlike ANTs notion of translation and Spivaks concept of delegation, the displacement model highlights the paradox of representation in the making of subaltern agency. This is not entrepreneurial agency. Patients cannot afford to represent their alternative practices, challenge hegemony, and claim credit for doing so. The many displacements and achievement of invisibility as they achieve agency are precisely the conditions of possibility needed to sustain life in the context of dialysis. This is practically crucial. But analytically, what is most remarkable is that patients resolve their problems by adapting dialysis practices to those of alternative medicine or vice versa as if they have made no difference at all. Thus proposing the displacement perspective is not to translate or speak for the silence of the subaltern; instead, it is to envision multiple possibilities, to find ways of joining force with the subaltern, and of realizing alternative

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ontologies, institutions, and subjectivities in the making and remaking of day to day realities.

Conclusion
This article has adopted an enactment approach to explore the practices of dialysis and elaborate an alternative displacement framework of agency from the point of view of the subaltern. The cases of dialysis patients suggest that patients have to go through a process of problematization, distribution, hybridization, and restabilization, in order to sustain the coexistence of their alternative practices with dialysis. The article shows that patients displace the problem, the therapies, themselves, and their situations in situated enactments. The shifting configurations of patients agency in these moments are elaborated to interrogate the process of problematizing, interessment, trial, and representation in a translation model. Unlike entrepreneurs, patients are subordinated to hegemonic translations by medical personnel, biomedicine, and a positivist biomechanical understanding of the body. The translation model that prioritizes the trope of trial and contest for representation is unable to recognize patients elusive displacement in making their agency. Unlike entrepreneurs who transform the world by interesting others, enduring trials, and becoming spokespersons for all, those patients who manage to displace and sustain the coexistence of multiple worlds avoid interesting, still less confronting, the hegemonic actors and claiming representation for themselves. This article proposes displacement as agency as an alternative. But this is only a beginning. The translation model conceptualizes particular forms of entrepreneurial agency in epic moments of world transformation or in fields that prioritize representation. But given the ever changing intersection of multiple worlds, what I have written explores the paradox of representation in making subaltern agency and suggests that different forms of subaltern agency are made and displaced so as to render themselves unrepresentable. If this is the case, it is vitally important to explore the various patterns of dynamics that arise in different subaltern contexts; examine the different tactics subalterns devise to manage the intersection of multiple worlds and the consequences for their agency; and to consider the possible ways in which these patterns and tactics teach us to diffract our understandings of the multiple forms of agency that make up our world. Such is the challenge.

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Acknowledgment
The author would like to thank all the interviewees for their kind help with this study. The author is grateful to late Susan Leigh Star, John Law, and the anonymous reviewers for their comments and recommendation on drafts of this article. The author also appreciates financial support from the National Science Council (952412-007-005-MY2). The article is entirely the responsibility of the author.

Declaration of Conflicting Interests


The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The research was supported by the National Science Council (95-2412-007-005-MY2).

Note
1. Haemodialysis treatment is based on an osmotic apparatus that extracts excess electrolytes, water, and uremic waste from the body of a patient of End Stage Renal Disease (ESRD) by filtering the blood drained out from an arteriovenous fistula. A fistula is constructed either by connecting to an artery and a vein or by implanting artificial tubing in the arm.

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Author Biography
Wen-yuan Lin is an Associate Professor in General Education at the National Tsing-hua University, Taiwan. He publishes on issues in patients practices, change of medical regime, users in technological innovation, and empirical ontology. He serves on the Editorial Board of Taiwanese Journal for Studies of Science, Technology and Medicine.
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