Nursing Inquiry 2009; 16(3): 261272

Feature

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: 261272 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, quantiable efciency 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 Kuhns paradigms to Bloors strong programme of Sociology of Scientic Knowledge. Following this, I attempt to explicate the thought of Bruno Latour as a philosophical alternative to Sociology of Scientic Knowledge. Next, I outline the radical pluralism of William Connolly in an effort to demonstrate its similarity to Latours philosophy and nally 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 scientic 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 Freidsons major work, Profession of medicine, it has been argued that doctors have lost a signicant 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 dene, 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, quantiable efciency 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 benets and side-effects of medical intervention are of the

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same root technological objectivation of diseases. Or, as Roy Porter (1998, 718) concluded in his landmark work The greatest benet to mankind: A medical history of humanity medicines nest hour is the dawn of its dilemmas its triumphs are dissolving in disorientation. Medicine has led to inated expectations, which the public eagerly swallowed: medicine will have to redene its limits even as it extends its capacities. Yet, despite years of important critique from diverse disciplinary and theoretical perspectives, from Marxist and critical theory to feminism and postmodernism, as well as from within medical science itself (Foucault 1973; Illich 1976; Barsky, 1988; Freidson 1988; Candib 1995; Szasz 2001; Callahan 2003; Lupton 2003; Conrad 2007; Markle and McCrea 2008, to name only a few), medicine has been largely undeterred in its modern mandate of knowledge production, transfer and application. However, The presentation of medical science as a progressive march forward in the conquest of illness to the benet of humankind fails to recognize that medical knowledge is never disinterested (Annandale 1998, 5), to which I would add, neither is it without social and political side effects, what Illich (1976) termed social and cultural iatrogenesis. Medicine is, in many respects, still the dominate epistemology and a problematic one at that. As nursing continues to eagerly welcome and indeed champion epistemological medicine, that is evidence-based practice, knowledge transfer, research utilization, outcomesbased practice, quantiable efciency and effectiveness, it risks becoming little more than a medical science addendum and indeed one that inherits the problems now facing contemporary medicine. Moreover, the agenda of advocacy that nursing has recently assumed, both patient rights and existential (Gaylord and Grace 1995), might well be lost, or certainly rendered impotent, in the rush to facilitate knowledge transfer and application. Add to this the fact that, with nursing situated closer to the patient than any other healthcare profession, there is a very real potential that an uncritical regime of knowledge transfer and application could not only disrupt the act of advocacy, but also serve to foster the opposite effect. That is, to put it in Foucaultian terms, to discipline patients with knowledge:
Nurses are at the exing point of the states requirements and of individual and collective aspirations. They occupy a strategic position that allows them to act as instruments of governmentality. Consequently, nurses constitute a fullyedged political entity making use of disciplinary technologies and responding to state ideologies.(Perron, Fluet, and Holmes 2005, 536)

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. Although nursing certainly does require knowledge to be practiced, I contend that a better understanding of the larger, which is to say sociopolitical context in which knowledge is generated, legitimated, disseminated and applied will perhaps lead to a more sophisticated and hence productive view of nursing as a unique profession, rather than a mere adjunct to medical practice. In other words, without a critical appreciation of the (social) nature of knowledge and its application, as apposed to Cartesian rationalism, nursing cannot but remain subsumed under the largely positivist, and perhaps to a degree postpositivist, framework of medicine. To accomplish this, I shall attempt to bring together a political scientist (William Connolly) whose thought draws upon the work of numerous postmodernists and poststructuralists, 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. However, before I do that, I must make reference to a sociologist (David Bloor) who took Thomas Kuhn quite literally, that is radically, and happily embraced relativism. I will begin by tracing a philosophical line from Kuhns paradigms to Bloors strong programme of Sociology of Scientic Knowledge (SSK). Following this, I shall attempt to explicate the thought of Bruno Latour as a philosophical alternative to SSK. Next, I shall outline the radical pluralism of William Connolly in an effort to demonstrate its similarity to Latours philosophy and nally how such a position is germane to contemporary nursing. 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 scientic 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. 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, if you will, two theorists who come from very different perspectives (again, philosophy of science and political theory) yet appear to arrive a similar conclusions. It is my hope that this approach will provide a framework for future work concerning nursing theory, epistemology and practice. It is also important to recognize that the work I am presenting (Latour and Connolly) is not without serious critics. For example, philosophers and theorists such as Haack (2003), Hacking (1999), Giere (2006), Ruse (1999) and numerous others, although sympathetic in many respects (to constructivist theory), may not nd what

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I have to say entirely convincing. Moreover, there are those who would simply dismiss it altogether. Be that as it may, I shall present the ideas, and indeed, welcome any criticism that comes.

BEYOND PARADIGMS
Thomas Kuhns (1970a) The structure of scientic revolutions was, and still is, a landmark in the philosophy of science. In many respects, it signalled the end of positivism as a viable philosophy and, or course, introduced the now ubiquitous concept, paradigm. The problem with Kuhn, and his eventful paradigm, is however, guring out what he meant by it. There is what he appears to express in Structure :
As in political revolutions, so in paradigm choice there is no standard higher than the assent of the relevant community . Like the choice between competing political institutions, that between competing paradigms proves to be a choice between incompatible modes of community life. (Kuhn 1970a, 94)

of science can, and indeed, should be explained sociologically. In other words, when a dispute or controversy arises between two scientic theories (paradigms), the decision to accept one over the other as true is done for sociological reasons rather then epistemological. This is to say that scientic theories, methods, and acceptable results are social conventions there is no Archimedian point (Bloor 1991, p. 43 4). 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, especially a relation of the kind we take for granted in our science (Bloor 1999, 110). Indeed, in a recent study, Bloor (2007, 251) not only accepts the label of relativist, but, moreover, he embraces it Despite this growing consensus, I do not believe that relativism constitutes a danger. On the contrary, I think a properly formulated relativism should be warmly welcomed. Relativism certainly is at the centre at Bruno Latours thought as well. Yet he does not welcome relativism so much as it transforms into something much more productive relationism:
Nothing is, by itself, either reducible or irreducible to anything else. Never by itself, but always through the mediation of another . If the question of relativism is insoluble, relativist relativism or, to put it more elegantly, relationism presents no difculty in principle . Relationism will serve as an organon for negotiations over the relative universals that we are groping to construct.(Latour 1994, 114)

Then there are his responses, following Structure, to critics who accused him of relativism, his Postscript (to the second edition of Structure), his Second thoughts on paradigms (Kuhn 1977) as well as his more recent work. For example, he writes in Reections on my critics it is emphatically not my view that adoption of a new scientic theory is an intuitive or mystical affair, a matter for psychological description rather than logical or methodological codication (Kuhn 1970b, 261). Indeed following the furor of Structure, Kuhn changed, or reworked, paradigms into what he called exemplars and disciplinary matrices (Kuhn 1977, 463). These later works of Kuhn, some have suggested, might well represent a signicant retraction of what was said in Structure, though Kuhn no doubt considered it a clarication. In any case, Kuhns work and the controversy that often surrounds it has spawned a number of differing schools, all of them attempting to deal with relativism in one way or another; from the postpositivism of Lakatos, Laudan and others, to the social epistemology of Steven Fuller and, of course, the SSK, the strong programme in particular. It is the latter that concerns me here, as a means of getting at the thought of Bruno Latour. Bloor then, as one example of the strong programme of SSK, seems to take the relativist views of Kuhns work quite literally. In essence Bloor claims that the weak programme of SSK (begun by Robert Merton), which claims that the errors, failings and mistakes of science and scientists are due to sociological reasons, does not go far enough. He argues for a symmetrical understanding, the symmetry principle, of scientic knowledge in that both the successes and failures 2009 Blackwell Publishing Ltd

Latours early work, however (e.g. Science in action), seems to position itself squarely within the Strong Programme tradition:
Since the settlement of a controversy is the cause of Natures representation, not the consequence, we can never use the outcome Nature to explain how and why a controversy has been settled.(Latour 1987, 99)

Indeed Bloor (1999) does in fact label Latours work SSK. However, Latour (1999b, 115) thought it at attempt to move Beyond SSK and in so doing he admits that Bloors critique makes:
my defence more difcult since I would be at great pains to say which paper, chapter or book is representative of my position. 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.

This is the problem then of explicating Latours thought, not unlike with Kuhn, that is, guring out what he means. Quite obviously, I do not have the time and space in this study to outline the many of all the changes Latours thought from Laboratory life: The construction of scientic facts (with Latour and Woolgar 1986), to Science in action: How to

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follow scientists and engineers through society (Latour 1987), through to We have never been modern (Latour 1994), Pandoras hope (Latour 1999a) and nally to Politics of nature (Latour 2004), to say nothing of his numerous studies. I will then sketch only the major elements that demonstrate its differentiation from, and attempt to move Beyond, SSK.

tion, to form hybrids of natural social, or subject object, human non-human or again quasi-objects quasi-subjects. For example:
The smallest AIDS virus takes you from sex to the unconscious, then to Africa, tissue cultures, DNA and San Francisco Press the most innocent aerosol button and youll be heading for the Antarctic, and from there to the University of California at Irvine, the mountain ranges of Lyon, the chemistry of inert gases, and then maybe to the United Nations, but this fragile thread will be broken into as many segments as there are pure disciplines. By all means, they seem to say, let us not mix up knowledge, interest, justice and power. Let us not mix up heaven and earth, the global stage and the local scene, the human and the nonhuman.(Latour 1994, 23)

LATOUR: BEYOND THE MODERN CONSTITUTION

Latours original target is the founder of both science and the modern world Rene Descartes, and more specically the Cogito (I think therefore I am). As Latour (1994, 29) puts it the modern Constitution invents a separation between the scientic power charged with representing things and the political power charged with representing subjects. Dualism in its most pure form we might say. In other words, things, nature with all of its properties, laws and knowable processes, and subjects, the aggregate of Is in I think therefore I am are separate and distinct, in Latours terminology, they are in a modern state of purication. Indeed, they are two extreme poles, or two distinct entities that interact only in that the subjective is the knower, the user, the manipulator of the objective, or nature, a process that Latour refers to as mediation. However, for modernism Nature and Society must remain absolutely distinct: the work of purication must remain absolutely distinct from the work of mediation (Latour 1994, 32). Moreover, in addition to the utilitarianism of science in fullling the growth and development needs of human beings, it also services them by providing a standard of judgment beyond themselves, an appeals court as it were, in the rather inevitable case of dispute. According to the [modern] constitution, in case of doubt, humans are better off appealing to nonhumans (Latour 1994, 23). Viewed in this manner, the modern world is little more than a cosmic civil court proceeding intended to adjudicate disputes and maintain order. Without this constitution, the engineering of the modern world would simply not have been possible. However, that is Latours point we have never been modern. Latour (1999a, 1999b, 276) asks Is the modernist imprisoned and enchained by his delusionary and muddled belief?. The belief that belief and truth are distinct, fact and ction (fetish) are dissociable, subjects and objects are distinguishable, nature and society are separate. Rather than speaking of things-in-themselves though, Latour characterizes them as quasi-objects (or quasi-subjects). Moreover, nature and society (subject and object) have always been interacting and communicating reciprocally, again media-

Though we would not have any problem suggesting that subjects have an effect on objects, we nd that objects have effects on subjects. And moreover, that they both have histories if you will.
Every scientist knows in practice that things have a history too; Newton happens to gravity, Pasteur happens to the microbes, intermingle, bifurcate, happen, coalesce, negotiate, ally, be the circumstances of: these are some of the verbs that signal the shift in attention from the modernist to the nonmodernist idiom. (Latour 1999a, 1999b, 282)

Hence, 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, things (objects, nonhumans) can be shown to extend agenda and agency-like behaviour upon humans as well. Latour (1999a, 1999b, 122) claims that:
there is no other way to dene an actor but through its action, and there is no way to dene an action but by asking what other actors are modied, transported, transformed, perturbed, or created by the character that is the focus of attention.

Although there is no attempt here, by Latour, to suggest that things (non-humans) have intentionality (Latour is certainly not an animist). Rather, it is suggested that human intentionality, while commonsensical for us from a Cartesian position, is not with out its philosophical problems. It might be argued that intentionality, rather than being the simple product of an internal free will, is just as much an external (structural if you will) set of inuences and processes, not unlike that of non-humans. Thus, for Latour, Is and things join forces to generate hybrids of coexistence. We might even refer to collectives of hybrids, or networks of connectivity, as a web of reality a common world as it were.

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Hybrids of co-dependence and co-existence have always existed, been produced, utilized, altered and redened. Moreover, like all relationships, there is, for lack of a better way of putting it, an evolution over time, which is to say change, and moreover such change is not a supercial phenomenon, a reorientation of secondary qualities or mere appearances, but rather of a fundamental nature, the base conguration of reality. Latours more recent work then, particularly Politics of nature, cannot be at all considered SSK in that for Latour, there is simply nothing that is distinctly social, nor for that matter is there a singular thing called nature. Rather, there is only what he calls a collective or common world (Latour 2004), composed of, or perhaps more correctly constructed with, diverse elements that are all in effect some mixture, or hybrids, of the social and the natural; human and non-human. However, this common world should not be confused with universalism or absolutism. The elements that constitute the collective are not only distinctive and dissimilar, but indeed they are also given to change, in that new elements, different hybrids and unique substances come into being. Most importantly, the composition of this collective is, invariably, an act of politics. Not everything is political, perhaps, but politics gathers everything together, so long as we agree to redene politics as the entire set of tasks that allow the progressive composition of a common world (Latour 2004, 53). 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, 235). In other words, knowing (scientic evidence) does not itself constitute a course of action, it provides possibilities if you will, from which to then determine a course of action or construct a social order. Moreover, the construction of a social order is not, or should not be, performed without recourse to the multiplicity of voices, perspectives and difference that it contains. Latour then distinguishes Science from the sciences, where Science refers to the politiciszation of the sciences by epistemology in order to make public life impotent, while the sciences in the plural and lowercase, are skills used to constitute the common world and take responsibility for maintaining the plurality of external realities (Latour 2004, 249). Scientists then are those individuals whose task it is to speak for, or give voice to the non-speaking members of the collective non-humans. This does not, however, endow them with some natural right to determine or dene reality based on such skills. Thus we need to abandon Science in favour of the sciences conceived as ways of socializing nonhumans, and as well adopt a politics dened by the progressive composition of the good common world (Latour 2004, 2009 Blackwell Publishing Ltd

235). Thus, the sciences, knowledge indeed epistemology, are subject to the due process of a democratic political procedure, diplomacy as he puts it. Latour contends that heretofore epistemology, namely Science, has been used instead of a democratic composition of the world, and, in his opinion, to the detriment of the collective. It is not only the practice of science and technology that epistemology has rendered opaque, but also that of politics all for the most implausible political project: that of doing away with politics (Latour 1999a, 1999b, 215). In other words, ignoring democratic due process in favour of Science rather than using scientic 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, transformation, alteration, reconguration. etc.). The very process of knowing then formerly understood as a society nature separation, or epistemology, 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.
The examples of ties between conceptions of nature and conceptions of politics are so numerous that we can claim, with good reason, that every epistemological question is also unmistakably a political question . Against the epistemology police, one must engage in politics, and certainly not epistemology.(Latour 2004, 17)

Take for example, evolution, quantum mechanics or genetics. Latour does not argue that there is not realness to them (i.e. they are not just social constructions), rather he would ask: (i) how are they to be incorporated into a collective, and (ii) what conceptions of nature do they assume? Forgive the extreme example, but for the Nazis genetic and evolutionary knowledge represented certain conceptions of nature. Moreover, they (genetics and evolution) gained their use, and power, by recourse to scientic authority and epistemology. The point is that, for Latour, knowledge cannot be separated from conceptions of nature and hence politics. To give primacy to epistemology, that is certainty, objectivity, detachment, neutrality or any other kind of dualistic descriptor, is for Latour an act of violence of sorts that short-cuts a necessary democratic ethos.
By using objectivity to short-circuit political procedures, 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, to force their way through.(Latour 2004, 55)

To be sure, the use of the term violence here might well generate some legitimate objection. Indeed, it has been used by postmodernists, feminists, postcolonialists and the like to gain some metaphorical traction, after all who is not against

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violence? However, what Latour means to suggest, as I have previously explained, is that knowledge itself does not predict, or condition its use. To know something says little about how such knowledge should be used, what it contributes to a collective, or if it should be used as a constituent of the collective at all and again what conception of nature it entails. To assume that one knows and such knowing constitutes a given action, without deliberation (politics), effectively suppresses other forms, types and avenues of action this is what Latour means by violence. In summary then, Latour is a constructionist, but not a social constructionist in that for him, there is nothing uniquely social and by extension there is nothing that is distinctively nature (they exist as hybrids of social nature). Latours constructionism refers to just that constructing, or perhaps building is a better metaphor and at the same time building is politics. Such construction must be democratic, for Latour, simply because without epistemology (certain knowledge) the building of a common world must take account of the diversity within it.

CONNOLLY: RADICALIZING DEMOCRACY

William Connolly is no more of an epistemologist than Bruno Latour. Moreover, his view of epistemology is quite similar to Latours:
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, any remaining issues will either be resolved through that method or shown to be irrelevant . The primacy of epistemology thereby treats the ideas of subject, object, representation, and knowledge as if they were already xed in their range of application. The attraction of this perspective resides in its claim to bypass issues that might otherwise contaminate, derail, or confound the operational self condence of the human sciences.(Connolly 1995a, 1995b, 6)

Connolly begins by recognizing that diversity or pluralism has become a well-accepted position in contemporary social and political thought, while acknowledging a signicant threat from various fundamentalist factions. However, he does not believe that such an understanding goes far enough. He contrasts conventional pluralism with what he calls the pluralization of pluralism or radical pluralism. These roughly correspond to modern and postmodern versions of pluralism respectively. The former pluralism, which he associates with Alexis de Tocqueville (primarily Democracy in America), understands diversity to be the result of unity, or put differently, behind all diversity is to be found a unity (a general agreement or consensus if you will) from which diverse elements, potential differences, emanate. A conventional pluralist celebrates diversity within settled contexts of conict and collective action. Often diversity is valued because putative grounds of unity (in a god, a rationality, or a nationality) seem too porous and contestable to sustain cultural consensus (Connolly 1995a, 1995b, xiii). Although conventional pluralism often does recognize the difculty or problem of accord and harmony regarding fundamental issues, there generally does:
prevail a set of general presuppositions about the terms of national security, the basis of gender difference, the normality of heterosexuality, the source and scope of rights, the monotheistic or monosecularist basis of morality, the shape of the economy, and the generic character of justice, reason, identity, and nature.(Connolly 1995a, 1995b, xiv)

However, there is a much greater similarity between Latour and Connolly than mere anti-epistemology. Indeed, as we shall see in a moment, Connolly very much elevates politics, and democratic politics in particular, to the position of epistemology, or at any rate the one formerly held by epistemology. Before we can make sense of Connollys work, we must rst understand what he refers to as his ontopolitical matrix. The explication of this concept is carried out, for the most part, in The ethos of pluralization (Connolly 1995a), although it is to be found throughout his other work, Why I am not a secularist (Connolly 1999) and Neuropolitics: Thinking, culture, speed (Connolly 1995b) as well as a plethora of studies.

In other words, despite a nod to the importance and even necessity of tolerance and the valuation of diversity, such an understanding often presupposes some form of agreement or consensus with respect to fundamental sociopolitical concerns a procedural framework if you will. The problem with such thinking, in Connollys view, is that it rst misrecognizes the paradoxical relation between a dominate constellation of identities and the very differences through which the constellation is consolidated and, second, misrecognizes new possibilities of diversication by freezing moral standards of judgement condensed from past political struggles (Connolly 1995a, 1995b, xiv). Fundamental agreement is, for Connolly as well as Latour, not necessarily fundamental agreement; moreover social and political change, again for both Connolly and Latour, does not only happen at a supercial level of apparent diversity, but rather at the very foundation upon which it rests. To paraphrase an old epistemology critique (Allen, 2004) it might well be diversity, like turtles, all the way down? If so, and Connolly suspects that it is then presumptions within [conventional pluralist] understandings must be reworked in

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order to reshape the pluralist imagination (Connolly 1995a, 1995b, xv). Enter the pluralization of pluralism or radical pluralism:
an ethic of cultivation rather than a morality of contract or command; it judges the ethos it cultivates to exceed any xed code of morality; and it cultivates critical responsiveness to difference in ways that disturb traditional virtues of community and the normal individual. It does not present itself as the single universal to which other ethical traditions must bow. Rather, it provides a prod and counterpoint to them, pressing them to rethink the ethics of engagement and, crucially, to rework their relations to the diversity of ethical sources that mark a pluralistic culture. Such a postNietzschean ethic resists oligopolistic control over the currency of morality, while afrming the indispensability of ethics.(Connolly 1995a, 1995b, xxiv)

importantly democratic negotiation. Moreover, both theorists seek to transform the politics of reality, 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, into a reality of politics, in which reality is determined (again constructed) by (democratic) political activity.

NURSING AND THE REALITY OF POLITICS

It should be clear at this point that, for both Latour and Connolly, reality is an act of politics or again political construction. Put differently, politics is the act of determining what reality is. This does not mean that, as Feyerabend (1975) put it, Anything goes. Nor does it imply that reality is merely a convention that can be constructed in an innite number of ways. Even Bloor (1991, 45), in his embrace of relativism, would not concede this: to say that the methods and results of science are conventions does not make them mere conventions. This would be to commit the unspeakable blunder of thinking that conventions are things that are trivially satised and essentially undemanding. It does, however, mean that, with political change, which is to say doing things differently, comes a change in what constitutes reality. Although this rather unsophisticated way of putting it might well seem trivial, it is not at all. It is, in essence, the opposite of the multicultural mono-natural way of viewing the world, which suggests that there is a single reality (nature) and multiple, perhaps competing, ways of seeing it (culture or society) dualism or the politics of reality. To say that reality is politics means that political conguration (societal construction) determines what reality is monism or a reality of politics. For the majority of that latter half of the twentieth century, nurse theorists and academics have been attempting to explicate a foundation upon which to rest nursing practice. It has also been important to many for nursing as a discipline to articulate a unied conceptualization of itself, similar in many respects to medicine. As Cody and Mitchell (2002, 4) put it contemporary healthcare issues demand that nurses know who they are and what they are about, how to identify and actualize their societal mission, and how to communicate it to others. A number of philosophical and theoretical possibilities have been proffered as a viable foundation for nursing; however, the overwhelming majority of these proposals suggest that nursing as a practice is, or ought to be, a postpositivist enterprise. Although postpositivist thought is neither circumscribed nor invariant, almost all of it does rest on some understanding of epistemology as a

Translated, one cannot have (an) identity without the existence of difference. everything depends upon how this paradoxical relationship [identity difference] is negotiated (Connolly 1995a, 1995b, xxi). Indeed, Connolly subscribes to a Nietzschean becoming over a Kantian being. For him, there is no being, that is durability and stability over time (or even at any point in time), only becoming, which is to say change over time as well as negotiation in place time. Hence, there is no binding unity beneath diversity, there is no universally valid operating consensus behind difference, nothing is fundamental (Connolly 1995a, 1995b, 1) and most importantly change, perspective, transformation, context, revolutions, outlook and on and on, all conspire to not only refashion and recongure identity difference, to use Connollys preferred idiom, but indeed generate new and unimagined possibilities and potentialities to which a truly pluralist society must be responsive. Responsiveness is then, we might say, the procedure of Connollys ontopolitical matrix, and moreover, it is what he terms critical responsiveness that makes the difference. As he puts it elsewhere:
where tolerance implies benevolence toward others amid stability of ourselves, critical responsiveness involves active work on our current identities in order to modify the terms of relations between us and them . For example, as heterosexuals respond to the politics of becoming by which a previous history of medicalization and demoralization of homosexuality is recongured they are also pressed to acknowledge for the rst time that heterosexuality is not rmly grounded in the universality of nature, the commands of a god, or the automatic outcome of normal sensual development.(Connolly 1999, 623)

Such a process or procedure applies equality well to innumerable other social norms, ethical precepts, legal precedents, political patterns, historical conventions and even indeed scientic cognitions. Knowing for Connolly then, like Latour, is sociopolitical negotiation and more

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foundational tenant. In an important sense, nursing postpositivists, or again the great majority of them, subscribe to some variant of dualism, where subjects (societies) come to know objects (nature) and in so doing use such knowledge to intervene, in some manner, in the lives of individuals, families, communities and even cultures for the better, in effect scientic progress. For example, in a recent issue of Canadian Nurse, Canadian Nursing Association president Marlene Smadu (2007, 2) claims, quoting Paulo Freire, that Education is THE political activity. Smadu (2007, 2) concludes the message with Lets follow Freires example and get political: use education to bring about the changes that need to occur in our profession, our health system, our communities and, yes, the world. Although few would debate the spirit of what Smadu is suggesting, her use of the phrase changes that need to occur is more problematic than it rst appears. For example, just what are these necessary changes that are so clearly needed, and does everyone agree? The epistemology answer is simply, though it is not really simple at all, that we do proper research, generate knowledge, transfer that knowledge, apply that knowledge and the result is the changes that need to occur. Recent development in nursing has suggested wide support for such an approach. 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, to use Deweys phrase, the epistemology industry, although perhaps it is more accurate to say that nurses have, historically, been assistants in the medical epistemology industry, who now demand access to it. In fact, Gordon and Nelson (2005, 63) have recently called for an end to angels in nursing, 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. Nelson (2006) even invites us, nurses that is, to celebrate knowledge (p. 22), moreover nurses can reclaim their scientic, medical, and technical knowledge without this being considered the sign of an uncaring nurse or a wannbe doctor (p. 23). While Bartels (2005, 221) puts it as succinctly as I think it can be put, nurses need more knowledge, more education, and more skills. Again questions like, knowledge for what, education for what, skills for what, as well as what kind of knowledge, education and skills, seem legitimate. We are perhaps witnessing the birth and early development of what might be called the next nurse, as opposed to the new nurse (Salvage 1990), which in some respects I am suggesting a return too. The next nurse is the advanced, autonomous, expert professional armed with a 268

sophisticated knowledge base (Betts 2007, 454) guided primarily by evidence-based practice, best practice guidelines and research utilization all set within a modernist agenda, perhaps not a wannbe doctor but, in many respects, medical epistemologist nonetheless. The age of Nightingale angels is certainly coming to an end (Gordon and Nelson 2005) and while this is probably a good thing, the next nurse, I suggest, is no less problematic. As Rorty (2004, ix) once put it the idea that the disinterested pursuit of scientic truth can be neatly separated from engineering, warfare, money, media, and politics is pretty well dead. Curiously, while nursing appears, as I have said, to be only now embracing epistemology (or demanding access to it), 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. More to the point, there are things to be done, or things that can be done, which require a change not only in supercially diversity, but rather fundamental conceptualization of what Connolly refers to as identity difference or what Latour terms the common world. For example, in another recent issue of Canadian Nurse, Pauly et al. (2007, 20), discussing the evidence for harm reduction policies, a cause recently taken up by nursing leaders, suggest that when nurses work in ethical climates in which negative attitudes and judgements prevail toward people who have substance use problems, the delivery of health care may be adversely affected. They conclude that it is incumbent on nurses to insist on a harm reduction approach for such individuals in all settings (p. 22). Most importantly though, they claim that there is a disturbing trend in Canada toward disregarding the scientic evidence, potentially jeopardizing public health initiatives designed to improve the health of those who use illicit drugs (p. 21). Although scientic evidence is certainly important in such an issue, neither Latour or Connolly deny that (small s) science can provide invaluable information for a society attempting to construct and or reconstruct itself, I contend that harm reduction is an act of politics that redenes drug use in our society and our response to it. In effect, it is a reconguration, or reconstruction, of the commonly held identity drug user. Moreover, it changes our political emphasis from stopping illicit drug use for the good of individuals and society, to tolerating some level and emphasizing the reduction of the harm associated with drug use, for the good of individuals and society, good being of course a relative term, or rather a political term that refers to a conception of reality.

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The point that I endeavour to make is that this is not simply a knowledge transfer application issue at all. Rather, it is a construction of reality that we determine. To be sure that Pauly et al. 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. However, there are also those who claim, with justication, that many of the same harms to individuals and society could be ameliorated if we managed to end drug use altogether. Moreover, the methodology and ndings of harm reduction science also has its critics (Davies 2007; Kall et al. 2007; Mangham 2007a). Take, for example, a recent exchange regarding harm reduction in the electronic journal Open Medicine. 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, moreover, that there is a consensus among health scientists concerning this position. Hence, it is the proper course of action. Yet he also admits that public polices arise through a complex process that is inuenced not only by information and evidence such as that obtained by research. Other essential and legitimate factors that affect policy-making include ideologies beliefs and interests (p. 6). He then posits that However, the health of the nation is placed in peril if our leaders ignore crucial research ndings simply because they run contrary to a rigid policy agenda driven by ideology or xed beliefs (p. 6). While on the one hand, Hwang admits that ideology is a legitimate factor in social decision-making, on the other he labels those who disagree with the research ideologues. Indeed the article is entitled Science and ideology. In a response to this article, Mangham (2007b, 1) not only questions the validity of the research Hwang is so condent in, contesting the consensus, 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, debate, and honest pursuit of truth that we need.

previously remarked, knowledge does not predict its own action. What is it then that makes us choose, for those of us that do, 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, epistemology as it were? Isnt it a form of what Connolly (1999, 62) calls critical responsiveness? Critical respondents enter into practices of self-modication in the very process of changing their recognition and treatment of the others already in motion. To put it another way, are we not altering our view of drug users, who they are, what they do, why they do it, in an effort to reduce the difference between us and hence change our treatment of them? Are we not reconstructing a reality, a common world, that now situates drug use and our knowledge of it within a web of connecting interconnecting factors? Such advocacy, of illicit drug use and that is certainly what it is to some extent, in the way that I have just described it, might well be termed democratic advocacy. By this, I do not simply mean, as defenders of nursing advocacy often do, the recognition and promotion of stable rights that have been formalized and sanctioned patient rights advocacy (Gaylord and Grace 1995). Nor do I only refer to the facilitation of voice, self-expression, exploration of meaning and self-determination existential advocacy (Gadow 1980) thought both are important. Gaylord and Grace (1995) are correct when they suggest that nurses are in the best position to be advocates for patients, moreover I also agree that:
patient advocacy is not merely the defence of infringements of patients rights. 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.(Gaylord and Grace 1995, 18)

What we appear to have then are two experts, epistemologists perhaps, arguing about what to do with drug users. Indeed, they are antithetical ideologues (remember Hwang admits that ideology is legitimate) who, presumably, agree on the importance of research, but disagree on the research ndings calling each other ideologues. In effect, we are presented with different views of drug use, different conception of what to do about it, and how to proceed different knowledge transfer application systems as it were. Again, as I have 2009 Blackwell Publishing Ltd

However, as both Latour and Connolly also attest, reality is a political assembly and furthermore politics is the act of constructing what is and is not accepted, legitimated, sanctioned, endorsed, authoritative, convincing and as well, what is and is not utilized, employed, developed, funded and so on. Thus, democratic advocacy is similar to both rights and existential advocacy; however, it recognizes that politics is not merely an organization of society, but also an ontology, which is to say reality. Furthermore, it demands not only that we be accepting and tolerate, but also that we work at modifying ourselves when confronted with us them dichotomies, that is active work on our current identities in order to modify the terms of relations between us and them (Connolly 1999, 623). Put simply, in order to see them differently we, that is us, must also become different. And

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nally, such an advocacy requires an understanding of change not only of the kind that we are aware of, can anticipate, predict and plan for (Smadus aforementioned view), but also, as Connolly suggests, the development of new, that is heretofore unimagined, modes of suffering.
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 redenition.(Connolly 1999, 68)

Suffering that is or might often be the result of, our, all too modern, belief in stability, unity and endurance of identities, kinds, designations, types and so forth, and our nave denition of knowledge as simply that which is unproblematically transferable, or applicable to a situation. Nurses then need to advocate for a politics of becoming that is typied by care for the plurivocity of being (Connolly 1999, 159), which has as its central aim the critical responsiveness to human suffering. From here, we can have all manner of discussions and debates about what evidence and knowledge mean and when, when and how to use them.

tion is something to be avoided. Rather it adds, signicantly I hope, to the advocacy agenda of nurses in that it recognizes, as I have tried to demonstrate in this study, that reality is political. And moreover, reality is, or ought to be, constructed by (democratic) due process rather than short circuited, circumvented if you will, by a modernist use of things like knowledge, evidence, research, science, efciency, effectiveness and so forth. Such democratic construction requires all voices, including the nonhumans scientists claim to speak for, to be heard during the assembly of reality. Hence rather than the politics of reality that characterizes the, so-called, science culture wars, I offer a reality of politics as the bases for nursing practice. I hasten to add that, while I do believe that the position I have attempted to outline and defend is a benecial one, and moreover holds great promise for nursing as a discipline, I do not claim that there is anything easy or simple about it. Both Connolly and Latour also readily admit this. I end then with a slight paraphrase of Latour (2004, 82):
Nothing proves, however, that the assembly is going to come off well, that the participants are all going to nd 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, nicer, more rustic, more bucolic, than the old politics.

CONCLUSIONS
I have attempted in this study to situate nursing within an ontopolitical matrix of radical pluralism. In effect, I have challenged the typically held belief (though certainly not by everyone) that nursing is, or ought to be, founded upon a postpositivist epistemology. Moreover, 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, or what might be termed postepistemological thought. For postpositivists, knowledge is provisional yet at the same time relatively secure, whereas for the postepistemologist, knowledge is inherently political and hence, for Latour at any rate, relational. I do not of course consider my position incontestable or even fully articulated at this point. Rather I have attempted to outline a position, using Latour from philosophy of science and Connolly from democratic theory, from which to view nursing and nurses as democratic advocates. I admit that I have only introduced the concept here and much work is required to develop and rene it. Democratic advocacy does not deny the need for nurses to defend the rights of patients, nor the importance of existential issues of advocacy. Nor does it claim that practicing nurses do not need knowledge and skill, or that knowledge transfer applica270

Finally, for those who might be, legitimately, critical of the radical thought that I have endeavoured to explicate, in that it tends to fragment into an unworkable, or impractical relativism, I offer Connolly (1995a, 1995b, xxi) claim that: The biggest impetus to fragmentation, violence and anarchy today does not emerge from political engagement with the paradox of difference. It emerges from doctrines and movements that suppress it.

ACKNOWLEDGEMENTS
The author would like to express thanks to Drs Jenny Ploeg and Catharine Tompkins from the McMaster University School of Nursing for assistance, support and critical feedback during the development of these ideas. Special acknowledgement is given to Dr Ploeg who read several early drafts of this manuscript and responded with important comments and criticism. 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. Finally, a profound thanks to Andrea Smith-Betts for both editorial assistance and the critical discourse that comes with it. 2009 Blackwell Publishing Ltd

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