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Orders and Their Others: On the Constitution of Universalities in Medical

Work

Universality, actor-network theorists have argued, is not a transcendent, a priori quality of a


body of knowledge or a set of procedures. Rather, it is an acquired quality; it is the effect
produced through binding heterogeneous elements together into a tightly coupled, widely
extended network. Likewise, formality is an effect created by the rendering docile of a
network, and by the concurrent production and channeling of a stream of standardized
inscriptions that afford easy manipulation.
Universality is depicted as an effect, but then it is often granted some of the qualities that
gure as a prioris in the received scientistic or technologically determinist tales.

Other theoretical traditions within STS likewise question these rhetorics. Social-constructivist
analyses, for example, also argue that the universality of technology or knowledge is an
emergent property: to them, a fact or a technology becomes universal when the relevant
social actors dening it share a common denition.

Inhisobligatorybookofpassage,ScienceinAction,BrunoLatourmadeitthesixthprincipleof
technoscience:'Thehistoryoftechnoscienceisinalargepartthehistoryoftheresourcesscattered
alongnetworkstoacceleratethemobility,faithfulness,combination,andcohesionoftracesthatmake
actionatadistancepossible'.Standardsaimatmakingactionscomparableovertimeandspace;they
aremobileandstable,andcanbecombinedwithotherresources.

Inthisprocess,theextensionandstrengtheningofnetworksisthetrickthatallowsuniversalitytotake
place:'Scientificfactsareliketrains,theydonotworkofftheirrails.Youcanextendtherailsand
connectthembutyoucannotdrivealocomotivethroughafield'.

These points taken together add up to an ambiguous and precarious status of 'universality'. We
introducethetermlocaluniversalitytoaddresstheseambiguities.Localuniversalityemphasizesthat
universalityalwaysrestsonrealtimework,andemergesfromlocalizedprocessesofnegotiationsand
preexistinginstitutional,infrastructural,andmaterialrelations.'Universality',here,hasbecomeanon
transcendentaltermnolongerimplyingarupturewiththe'local',buttransformingandemergingin
and through it. To capture the way in which standardization achieves a universal character while
feedingoffalreadyexistingnetworks,tograsptheemergentanddistributedqualitiesofuniversality,
andtoexploretheconsequencesoflocaluniversality,wefocusontheconstructionanduseofsome
specificmeansofstandardization:medicalstandardsorprotocols.Inourconceptualization,amedical
standardisviewedasatechnoscientificscriptwhichcrystallizesmultipletrajectories.

HistoricalTrajectoriesofLocalUniversality

Research protocols, such as oncology protocols, are the contingent outcome of processes of
negotiationsbetweenheterogeneousactors

Theprotocoldesigners,fundingagencies,thedifferentgroupsofinvolvedphysicians,patients'hopes
anddesires,organizationalfacilities,laboratorycapabilities,drugcompanies,thepatients'organs'own
resilience,andsoforth,allcomeintoplayinthenegotiationprocessesleadinguptothe'final'protocol.
Whatkindofdrugsareused,howtheyaretobedosed,whoshouldreceivethem:allthese'decisions'
arenotsomuchaproductofconsciouslydevelopedplansasaresultofthesecontinuous,dispersedand
oftencontingentinteractions.
Thecreationofaprotocol,then,istheresultofworkwidelyandlooselydispersedthroughspaceand
time.Neitheritsoriginnoritsdevelopmentcanbetracedbacktosingularitieswhetheracentralactor
oracentralhistoricalevent.Itisastrugglefoughtonmanydifferentfronts,indifferenttimes,bymany
differentnetworkbuilders.Theprotocolitselfmaterializescontingentlyoutofthecrystallizationof
multipletrajectories,yetits'universal'contentcanneverbewhollytracedbacktotheinterests,hopes,
orgoalsofanyofthese.Thecreationofaprotocolisopenended;closureisneverreallyachieved.
Creatorsoftenendupasthefirstusersoftheirinventions,systems,orprotocols.Usersblendtogether
with creators when they record their experiences, send feedback to researchers, and modify the
protocolitself.

Local universality, then, implies a context of practice, of multiple crystallizing and dispersed
trajectories, of reappropriation, repairing, combining, and even circumventing the protocols and
standards,ofleavingmarginsoffreedom,ofreminding,oflongprocessesofnegotiation,ofdiverse
interests, and so forth. It points at the distributed origins of standards, and at their distributed
productionandmaintenance.

A criao de protocolos, da forma como os autores colocam, referese produo de condutas


padronizadasparatratardesituaesnamedicina.ComoBrennercoloca,areabilitaopsicossocial
comeava a dar o ar da sua importncia. Entretanto, era baseada em um polipragmatismo sem
fundamentoscientficos.Aremediaocognitivaeraumaformadecoordenarepadronizaraaode
profissionais de sade, tendo como pano de fundo uma base cientfica. No hospitaldia do 16
arrondissement, os profissionais gostavam da remediao cognitiva, pois ela dava uma noo de
cientificidade,deconfiabilidadeaumaprtica.Tinhaseaimpressodequeaquiloquesefaziapossua
umvalor,eraafinadacomasnovastecnologias,comapesquisafundamental.Omesmoaconteciacom
Brigitte,quandoeladizque:ldentroacontecealgumacoisa.