The End of Genre: Curations and Experiments in Intentional Discourses (Postdisciplinary Studies in Discourse) 3031087461, 9783031087462

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POSTDISCIPLINARY STUDIES IN DISCOURSE SERIES EDITOR: JOHANNES ANGERMULLER

The End of Genre Curations and Experiments in Intentional Discourses Brenton Faber

Postdisciplinary Studies in Discourse

Series Editor

Johannes Angermuller School of Languages and Applied Linguistics The Open University Milton Keynes, UK

Postdisciplinary Studies in Discourse engages in the exchange between discourse theory and analysis while putting emphasis on the intellectual challenges in discourse research. Moving beyond disciplinary divisions in today's social sciences, the contributions deal with critical issues at the intersections between language and society. Edited by Johannes Angermuller together with members of DiscourseNet, the series welcomes high-quality manuscripts in discourse research from all disciplinary and geographical backgrounds. DiscourseNet is an international and interdisciplinary network of researchers which is open to discourse analysts and theorists from all backgrounds. Editorial board: Cristina Arancibia, Aurora Fragonara, Péter Furkó, Jens Maesse, Eduardo Chávez Herrera, Benno Herzog, Michael Kranert, Jan Krasni, Yannik Porsché, Luciana Radut-Gaghi, Jan Zienkowski

Brenton Faber

The End of Genre Curations and Experiments in Intentional Discourses

Brenton Faber Worcester Polytechnic Institute Worcester, MA, USA

ISSN 2946-5990     ISSN 2946-6008 (electronic) Postdisciplinary Studies in Discourse ISBN 978-3-031-08746-2    ISBN 978-3-031-08747-9 (eBook) https://doi.org/10.1007/978-3-031-08747-9 © The Editor(s) (if applicable) and The Author(s), under exclusive licence to Springer Nature Switzerland AG 2022 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Palgrave Macmillan imprint is published by the registered company Springer Nature Switzerland AG. The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

This book is for Thomas and Christianne Huckin who have graced our lives as role models, friends, and mentors, people with good hearts, quick minds, and boundless energy. For endurance, perspective, and patience beyond what should be acceptable the book is, of course, also dedicated to Rebecca.

Acknowledgments

“The wrong tools for the wrong job.” These seven words from Paul Rabinow’s Anthropos Today have been a confluence of inspiration and frustration for me throughout this project. In this short phrase I recognized the articulation of what is equally an enduring problem and a hazy solution for humanities-based inquiries into language, science, and collaborative action, the realm of professional discourse. But Rabinow’s phrase also resonated as a warning that prolonged this project through various experiments to develop, practice, and deploy new tools in the service of a yet-to-be-determined job: How does a humanities-trained linguist contribute to and teach about increasingly science-based professions? Can a humanities-trained researcher collaborate with scientists and engineers as an equal partner on projects of mutual interest? The search for new tools for more useful jobs motivated me through paramedic school and certification, continuous medical education, and my own pre-hospital clinical practice; into undergraduate courses, labs, and student projects exploring convergent spaces between the humanities and the sciences; and to new and productive collaborations with physicians and colleagues in the sciences and engineering. Accordingly, there are numerous people to acknowledge and recognize for their support and encouragement, for indulging my risk and recognition of working in places where someone like me would not usually show up, and for vii

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assisting me through new tools and jobs. Though we have only briefly met once, I thank Paul Rabinow for his inspiring and challenging scholarship. I have lost count of the number of times I’ve returned to the bent, scribbled, and post-it-note-infected copies of his work for clarification, inspiration, and direction. I am grateful to Cheryl Finn and Richard Nydam at Quinsigamond Community College and to colleagues at Potsdam Volunteer Rescue Squad, Taylor Mullins, Tim Rivers, Chris Towler, Doug Bohl, Coreen Bohl, John Mitchell, Mike Ober, Tam Veith, Jerry Dibble, Matt Bruckley, Scott Grant, Travis Hanson, and Jeff Doyle and Andy Teig for training, education, skill acquisition, and their collegiality and friendship. Thanks to Dr. Jim Ledwith, Mike Fisher, and the volunteers at the Free Clinic. Thanks as well to David Caprette at Rice University for his assistance and excellent resources for understanding mitochondria and the Kreb’s cycle and Natalie Farny at WPI for lending her expertise in the area. I am indebted to George Dealy at Dimensional Insight for his insights, conversations, experience, support, and for helping me better understand and appreciate the value of a truly integrated humanities education. For sustained encouragement across the years that encompassed this book, I will be in continuous debt to Kelly Cargile-Cook, Michael Salvo, Mark Zachry, Elizabeth Angeli, and Julie Ford. Thanks as well to Bruno and Matthew for inspiration and common sense and Dr. Julie Veith, my co-author in other venues, who helped me cultivate tools in case study and clinical writing, projects that have now become central to my own teaching and student projects. I am grateful to students Kelsey Krupp, Nirali Parekh, Kimberly Codding, Stephen Foley, Allison Simpson, and Madeline Manfra-Levitt, whose projects became exemplary ways to integrate science and the humanities. At Worcester Polytechnic Institute, I am indebted to the Biomedical Engineering Faculty who have welcomed me as a full member of their department. Special thanks to Kris Billiar, Jeannine Coburn, and Adam Lammert. This book narrates personal, historical experiences including my own medical encounters with clinicians and encounters where I have provided patient care in pre-hospital and primary care settings. In writing these accounts, I have changed demographic and identifying data and in some cases, I have combined several events into one experience to protect the

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identity of patients and participants. Details of my own medical information and diagnosis are as accurate and comprehensive as was explained to me and as I came to understand in the process of my own research. Medical cases and information are not included for medical instruction but as example situations and events in which the intersection of intention and professional discourse was salient. The details of these descriptions are as I recall them and any mistakes in these recollections, medical data, pathophysiology, or disease processes are entirely my own. The history of nanotechnology in Chapter 4 has been reworked from the originally published Faber Brenton, 2006. Representations of nanoscience and technology in popular media. Technical Communication Quarterly. 15:141–169. A very early version of Chapter 4 was presented as, “Nanotechnology and the city: Space making, utopia, urban myth” at Organizational Symbolism XXIII in Manchester UK, July 2008. Sections of Chapter 6 were initially developed as presentations for the 2013 conference of the Association of Teachers of Technical Communication and the 2013 ACM SIGDOC conference with Keith Gagnon (now Keith Gagnon, MD, PhD) as coauthor. Finally, I would like to conclude this preface with a brief stylistic note. As its own curation, the book’s chapters privilege narrative as an organizing style. At the same time, in my own reading I have appreciated and enjoyed the annotations, added explanations, and the tangents authors often place in their notes. I have endeavored to do the same here. When deployed as more than a simple list of citations, these parallel narratives offer something equivalent to a back stage pass to a space where writers are willing to divulge more than what the primary narrative can reasonably instantiate. I see in these notes a more intentional dialogue with the reader, one that is less constrained by the requirements of form and the continuity of narrative. That most readers will skip the notes entirely makes the intentional act of taking such a tangent so much more worthwhile and the information found there perhaps that much more valuable.

Contents

1 Personal:  Intentions, An Autobiography  1 Mitochondrial Function: Energy Production and Transport    6 Cytochrome C Reductase Deficiency: A Problem with Executing Intentions   8 Interruptions  10 Intentional Action: Tools and Equipment   12 Metrics, Analytics, Intention   14 2 Signaling  and Framing, From Interpretation to Production 25 Intention in Rhetorical and Textual Studies   28 Intention in Linguistics and Discourse Studies   32 Intention in Interpretation and Performance   35 Intention and Reproducibility: From Interpretation to Production  39 Intention as an Ethical Project   42 What Is the Intent of Critique?   47 Intention as Discursive Practice   50 What Goes Around Comes Around   53 Experiments: Interpretation and Production   56 Intention as a Speculative Instrument   57 Experimentation  59 An Intentional Humanities   60 xi

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3 W  riting: After Intention 69 Meaning Without Empirical Referent   72 Chapter Summary  72 The Intentional Fallacy   75 Empiricism and Significance   77 Obscuring Intention in Student Writing   80 Restoring Intention  84 Intention and the Problem of Genre   86 Contrived Exigence: Situation and Intention   88 “The Self Is at Stake” Intention, Alienation, and Significance   91 Conclusion: Rereading the Intentional Fallacy   95 4 Design:  Nanotechnology and the City 99 Chapter Background: Intentionally Designed Spaces  100 Nanotechnology: From Micro to Macro  101 Rehabilitating Space: From Macro to Micro  104 An Intentional Humanities?  107 Near Futility? The Reply  109 Changing Frames: From Science to Urban Planning  112 Intention and Design in Academic Writing  114 Conclusion: Interrogating Good Intentions Yet Missing the Target 119 5 System:  Medicine, Intention, and Terministic Screens133 Act: Intention in Medicine—Retraining  136 Agent I: Intentional Heroism  138 Scene: The Intention of Unsustainable and Dysfunctional Health Systems  144 Agent II: The Antihero—Intentional Preventative Care  149 Agency: Intentionally Designing an Effective Health System  153 The Ratios I  156 Act/Agent/Purpose: The Patient, the Physician, and Intention at Cross Purposes  156 The Ratios II  163

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Agency/Scene/Purpose: Finance, the Electronic Medical Record, and Terministic Screens  163 The Tragedy of Drama: Act, Scene, Agent, Agency, Purpose  171 6 Practice:  Heuristics and Hermeneutics in Data Science173 Evoking Transparency  174 Analytics and Rhetorical Heuristics  175 Analytics and Meaning Making: What Is Hypertension?  178 Intention in Metrics: The Power of the Join  181 What Gets Counted: Case Study Discharge by 11:00  184 Intention, Factishes, and the Genealogy of Big Data  188 Toward Practice  191 7 Future:  Curations [Form + Action + Intention]197 Chapter Summary: Curating Intention in Practice and Purpose 202 TRAP Laws and Protecting Women’s Health  209 Curating the Medical Encounter  211 Curating Conversation for Patient Assessment  214 Curating Intent through Textual Silences  217 Intention, Textual Studies, and Instrumental Discourses  219 8 U  tility/Postscript223 Utility 227 Integration 229 I ndex235

1 Personal: Intentions, An Autobiography

It is a self-evident truth that people, whether in creating a new nation or simply beginning a new relationship, seek happiness. That they often go about it in the wrong way does not detract from the sincerity of their quest. – Roger Cohen (Cohen, Roger. 2015. Mow the lawn. New York Times. June 12. http://www.nytimes.com/2015/06/13/opinion/cohen-­mow-­the-­ lawn.html?action=click&pgtype=Homepage&module=opinion-­c-­col-­left-­ region®ion=opinion-­c-­col-­left-­region&WT. nav=opinion-­c-­col-­left-­region&_r=0)

About a decade ago, I was diagnosed with mitochondrial disease. Specifically, my neurologist said I had a cytochrome C reductase deficiency. The condition would cause progressive muscle deterioration for the rest of my life. The speed and extent of this deterioration were unknown. “It won’t kill you” he said, “You should be more careful about being hit by a bus.” But I would experience continued declining muscle function. Mitochondrial disease is a variant of the larger umbrella category Muscular Dystrophy. I am often a victim of my wife’s particularly wry sense of humor, and she now noted that, at 37, I was one of Jerry’s older kids. © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 B. Faber, The End of Genre, Postdisciplinary Studies in Discourse, https://doi.org/10.1007/978-3-031-08747-9_1

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The diagnosis was the end-result of five years of confusion, agonizing pain, tests, consults, uncertainty, and above all frustration. I first noticed symptoms when exercising. I had been a distance runner since childhood and had just started training for short triathlons, celebrating the mantra “swim, bike, run.” I began experiencing debilitating leg cramping, usually at the mid-point of my runs but also during the first 10–15 minutes of a bike ride, and when pushing off the wall in the pool. The cramping led initially to physical therapy, then a lower leg X-ray, spinal X-ray, spinal MRI, nerve conduction studies, and an ischemic exercise test. Finally a muscle biopsy from my right quadriceps, technically the vastus lateralis, confirmed the diagnosis. It is hard to write about these events without falling into well-worn genres or appearing glib. At the time, I was an Associate Professor of Communication and Media and interim department chair at Clarkson University in Potsdam, NY, a small village in northern New York State, about 20 miles from New York’s Adirondack Park. A socio-linguist, I had just finished my second book, a grammatical study of an organization going through a dramatic cultural change. My medical knowledge was limited to a 3-month course I took earlier that year to become a volunteer basic emergency medical technician (EMT-B). I had decided to become an EMT because a colleague told me I needed a hobby and should become more active in the community. I was invited to join the board of directors for our local food co-op but fell asleep at my first meeting. The volunteer rescue squad seemed more active. This book narrates a series of experiments encountering intention and since a good deal of the literature about intention describes intentions as personal, intimate, and usually secluded, this introductory chapter is curated as an autobiography. My interest in intention emerged from self-­ reflection and from a considerable amount of professional discomfort with the topic. This self-reflection wore familiar mental grooves about how and why I made what, in retrospect, were probably not very good decisions in response to a medical diagnosis. But, echoing Roger Cohen’s sentiment above, retrospectively, these actions were sincere and emerged from what I thought at the time seemed to be reasonable and appropriate intentions. What that previous sentence means and why it seems

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simultaneously hollow and prescient set me (partially) on the course of this book. Professionally, as someone who has dedicated a career to textual studies, I have labored under a long-held disciplinary prohibition against viewing a writer’s intention as anything but distraction and suspicion. This prohibition, the arguments it sparked, and the continuing debates follow in Chap. 3. As a quick preview, for good reasons and for reasons that seem somewhat short-sighted, what has come to be known as “the intentional fallacy” has continued to dismiss serious investigations into textual and authorial intention as unknowable and uninteresting. These arguments have extended into other text-based disciplines limiting both our understanding of intention and our ability to account for and assess the intentions that accompany a text. But, as I will argue through this book, this disinterest in intention is not just a methodological or categorical problem for retrospective text analysis. The chapters that follow attempt to address the relative inability of textual studies (and the humanities more broadly) to engage with and constructively participate in crucial problems of the late twentieth and emerging twenty-first century.1 This is a primary problem that informs each chapter and is narrated in this opening autobiography. To foreshadow a bit, I found that as a humanist-trained academic I had multiple rich, elegant, and highly nuanced tools and frameworks for retroactively analyzing and critiquing my diagnostic experience. But I also found that I had few tools for effectively engaging with and meaningfully acting in the face of my diagnosis. Turning away from retrospective critique and  I’ll note here that the social sciences have not experienced this problem to the same extent or in the same way as the humanities. At least in the United States, psychology, sociology, and related fields are well represented (if reduced and simplified) in the MCAT, LSAT, GMAT, and appear to be gaining relevance in Engineering projects reliant on user interfaces, technological adoption, and safety. The humanities have largely been cast as “performance” (art, theater, music) and without practical use in problem solving. This is especially so in the academic contexts in which I have worked (STEM institutions and medicine) where the humanities are seen as something that can potentially humanize professional practice (playing music for patients in a hospital for example) but not having direct influence on professional practice. Ethics could be seen as an exception for the impact it has on professional practice but as Rabinow notes (passim), even here ethics has been cast as largely retroactive (brought in after the problem has occurred as a corrective or critique when actors reach a crossroads and require consult) rather than participatory and constructively embedded in science or engineering as simultaneous production. Few American Engineering programs, for example, have required ethics courses to accompany their technical curriculum. 1

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toward positive planning, acting, and engaging with my diagnosis was like looking through a glass window into another world. I was impressed and jealous when I interacted with experts from disciplines that had productive ways to move from concept to research to practice and whose critiques were not ends in themselves but driven by a desire to improve practice and to solve problems. What was most difficult and strange here was not so much the scientific knowledge associated with disease. I could learn that. Instead, I envied how these disciplines nurtured an applied practice that my own disciplinary experiences in humanities-based textual studies lacked. Of course, there are multiple reasons and dynamics for this problem. In addition, intention, as a research subject, discursive feature, and motivator for research, has been both central and entirely absent in various generations of textual scholarship. This history and the various ways intention has been discussed and used in textual studies are developed in Chap. 2. In brief, the chapter shows how the concept migrated from a mental category in more cognitive fields to an aggregation of discourse and activity in fields like discourse studies and critical discourse analysis. The chapter will also show how the concept has been central to some of the most durable and contested debates in linguistics and post-structural discourse studies. The chapter also introduces some of the critical equipment I deploy in subsequent chapters as a way to experiment with intention as focus of study, a heuristic for production, and a site for systems analysis. In my effort to better understand the lack of disciplinary symmetry I witnessed when working alongside colleagues in more applied disciplines, I instantiated myself as close as possible within scientific practices to try to determine what were salient features of daily work that perpetuated a sidelining of humanities contributions that I held had application, utility, and viability to modern problem-solving. Working alongside engineers, physicians, urban planners, and then in establishing my own clinical practice as a paramedic, I came to see the importance of intention within these fields. I also realized the extent to which the textual humanities, as I write in Chap. 3, “gave up” on intention. I saw that without a better understanding, language, and ethics of intention, humanities-based textual studies did not have a way to usefully participate with fields highly

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motivated by intent. This book is a critical and productive reflection from and about these experiences and an argument that without a better developed humanistic understanding of intention, humanities-based textual studies will remain largely unable to effectively collaborate with the sciences, engineering, and medicine. Why intention? Over the experiments and interventions described in the book, I concluded that without a robust theoretical engagement with intention, we have few methods to identify, assess, and account for intention as a research problem (in discourse, action, structure, protocol, ethics). But equally importantly for my project is the extension: If we do not encounter intention as a complex theoretical or methodological concept in our analysis, intent is also missing as a productive component in our research design, objectives, and outcomes. As I show in Chap. 4, the humanities are unique in their academic writing in that it is unusual for researchers to identify the intent of their own research. Yet, statements of research intent are commonplace in engineering, science, and medicine. In the humanities, research intention is often naturalized and intuited by disciplinary readers.2 This is not to suggest that all is well in STEM disciplines and their drive toward research implementation, translational research, and technology transfer. There is a continuum between retrospective critique and uninformed practice. My goal for the chapters that follow is to find an appropriate balance that preserves and respects the expertise and utility of critique while finding suitable ways that critique can lead to informed, intentional practice. My concern is that dismissing intention as a critical and heuristic space has resulted in fewer humanistic discourses for interrogating and mobilizing intention and a learned inability or unwillingness to engage in intentional activity. In avoiding intention we have also neglected to build the equipment necessary to become active problem solvers in the twenty-first century.

 For analysis of academic writing in the Humanities, see for example: Peck-MacDonald, Susan. 1994. Professional Academic Writing in the Humanities and Social Sciences. Carbondale and Edwardsville: Southern Illinois University Press. Martin, J.R. 1993. “Life as a Noun: Arresting the University in Science and Humanities.” In M.A.K.  Halliday and J.R.  Martin, Writing Science: Literacy and Discursive Power (Chap. 11, pp. 221–267). Pittsburgh, PA: Pittsburgh University Press. 2

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As these various narratives intersected in my deficient cytochrome C, I found myself struggling to locate reliable discourses concomitant with the intent of my actions. Of course, I purchased and wore the green wristband associated with mitochondrial disease. I donated to the appropriate medical charities and read their associated websites. But, perhaps out of stubbornness, the rarity of the disease, and a quirky, at time capricious, imagination, the gap between what I intended to accomplish and what I was actually doing grew conspicuously. This became equally a personal and a professional problem and thus, as noted above, the overtly personal framing of this introduction.

 itochondrial Function: Energy Production M and Transport The mitochondria supply the vast majority (90%) of energy used in the body. They exist within and supply energy to all cells except red blood cells. Every scientific source I have used to study mitochondria opens with a singular metaphor “the mitochondria are the powerhouses of the cell.”3 Since energy cannot be created or destroyed, the mitochondria convert nutrient energy into useful energy, the energy used to fuel everything from bone and muscle growth to heart beats, bench pressing, digestion, and bike riding. The ultimate product of the mitochondrial process is the creation of adenosine triphosphate (ATP), which stores energy in a form that is available to the cell. A person with a form of mitochondrial disease is unable to adequately turn nutrition into energy. In technical terms, a certain percent of the protons are not generating ATP.  If the transport chain continues to degrade, the patient can experience continued deterioration. If the chemical deficiency stays relatively stable we would assume that the condition would remain constant.  The metaphor is now ubiquitous but was coined by Peter Siekevits in Scientific American. See: Siekevits. Peter. 1957. Powerhouse of the cell. Scientific American 197: 131–140. Also see: Cadenas, Enrique and Kelvin Davies. 2000. Mitochondrial free radical generation, oxidative stress, and aging. Free Radical Biology and Medicine 29: 222–30. Shuler, Michael and Fikret Kargi. 2002. Bioprocess Engineering Basic Concepts 2nd ed. Upper Saddle River, NJ: Prentice Hall, 20.

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Structurally, mitochondria are 1 micron in diameter and 2–3 microns in length. For comparative purposes, 25,400 microns equal 1 inch and a human hair is approximately 75 microns wide. Mitochondria are remarkably independent structures that divide on their own, have their own genome, and produce their own energy. A nice resource produced by David Caprette at Rice University describes mitochondrial structure as “a large wrinkled bag inside of a smaller unwrinkled bag.”4 Grossly simplified, the large wrinkled bag, the matrix, creates greater surface area for the chemical reactions that convert energy. The matrix has an inner lining and shares its outer lining with the surrounding smaller bag. Between the inner and outer lining are thousands of five distinct passageways (complexes) that facilitate transport from within the matrix into the smaller surrounding bag (the intermembrane space). The five complexes are like doors between the matrix and the intermembrane space. ATP is created by the electron transport chain through a series of reactions. The Krebs cycle, which takes place within the matrix, transforms carbohydrates, fats, and proteins into nicotinamide adenine dinucleotide + hydrogen (NADH) and flavin adenine dinucleotide (FADH2), among other products. NADH and FADH2 are the two key fuel sources converted into ATP. As NADH passes through the electron transport chain the process cleaves and pumps ten protons from the matrix through the complexes and into the intermembrane space. The sequence is: NADH  Complex I  Q  Complex III  cytochrome c  Complex IV  Complex V (ATP)

4 protons

2 protons

4 protons

H2O

As protons are separated and pushed into the intermembrane space they generate a sort of magnetic pull as they try to reunite with the electrons; the more protons in the intermembrane space the greater the pull (a proton gradient). At complex IV the leftover NADH electrons are

 Caprette, David R. 2005. The Electron Transport System of Mitochondria. http://www.ruf.rice. edu/~bioslabs/studies/mitochondria/mitets.html. Accessed: 4 June 2021. Also thanks to Tara Mann for walking me through the process again and again. 4

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combined with oxygen to create water as a waste product.5 At complex V (ATP synthase complex), the pent-up protons rush down an open channel that combines adenosine diphosphate (ADP) and phosphate ions into ATP. Caprette uses the metaphor of an energy-producing wheel or a turbine, like a water wheel, to describe this stage. The protons rushing through the channel spin the wheel and with each rotation ADP is coupled with phosphate to create ATP. The FADH2 provides a complementary process but enters the chain at Complex II and progresses to Q and then through the regular chain. The letters Q and C represent facilitators, Coenzyme Q facilitates transport from I and II to III, and cytochrome C facilitates transport from III to IV. While there is narrative efficacy in describing the process as a linear chain, Caprette notes that each complex “floats” in the fluid membrane and works independently of each other. This means that they swap electrons when they are in close proximity so, for example, any Complex III throughout the mitochondria can use cytochrome C to pass electrons to any Complex IV, and any Complex I can use any available Coenzyme Q to pass to Complex III.

 ytochrome C Reductase Deficiency: C A Problem with Executing Intentions At the sequences involving cytochrome C, two additional enzymes are necessary. A reductase allows the electron into the transport and an oxidase allows it out.6 Switching metaphors, if cytochrome C is a shuttle, the reductase opens the door for the enzyme to get in and the oxidase allows it to get back out at the destination (Complex IV). A reductase deficiency means that a certain percentage of electrons don’t make it to their intended destination because the shuttle doors do not open. The problem is twofold: Since not all the electrons get from Complex III to Complex IV fewer protons are pumped into the gradient  Breathing (respiration) cleans up the separated electrons at Complex IV and converts them into water as waste product. 6  see: http://neuromuscular.wustl.edu/pathol/diagrams/mito.htm, accessed 16 June 2021. 5

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so there is less available energy in the gradient. Less available energy in the gradient means fewer protons to spin the wheel and less ATP being produced. Less ATP means less available energy for both voluntary (walking, talking, running) and involuntary (breathing, heart function, brain activity) functions. A disruption in the electron chain can also create what are now called “free radicals.” These are like angry passengers at Dulles International who can’t get into a broken AeroTrain. The train arrives but the doors do not open. They are highly reactive, charged molecules that end up stuck at III. They are not combined with oxygen at IV and end up banging around the cells creating damage to the mitochondria and other associated structures.7 Mitochondrial disease is highly variable. Disease severity depends on the percent of mitochondria affected (mutated) and the severity of the specific mutation. Some conditions result in a small percent of mutation and because of the sheer number of mitochondria and complete complexes these conditions result in relatively benign symptoms and disease progression. Other conditions can result in mutation loads of 70–90% leading to serious muscular and organ damage. Conditions with a mutated mitochondria percent higher than 90% are usually fatal as the body cannot produce sufficient energy for basic metabolic functioning.8

 See: Cadenas & Davis, passim. See also Mitochondria Research Society, http://www.mitoresearch. org/treatmentdisease.html. Accessed 16 June 2015; United Mitochondrial Disease Foundation, http://www.umdf.org/site/c.8qKOJ0MvF7LUG/b.7934629/k.4C9B/Types_of_Mitochondrial_ Disease.htm. Accessed, 16 June 2015. 8  Kuicharczyk, Roza et  al. 2009. Mitochondrial ATP synthase disorders: Molecular mechanisms and the quest for curative therapeutic approaches. BBA: Molecular Cell Research 1793: 186–199. See also: Kühlbrandt, Werner. 2015. Structure and function of mitochondrial membrane protein complexes. BMC Biology 89, https://doi.org/10.1186/s12915-015-0201-x. Fernández-Vizarra, Erika and Massimo Zeviani. 2015. Nuclear gene mutations as the cause of mitochondrial complex III deficiency. Frontiers in Genetics 09, https://doi.org/10.3389/fgene.2015.00134. Rich, Peter. 2003. Chemiosmotic coupling: The cost of living. Nature 421. https://doi.org/10.1038/421583a. For mitochondrial disease advocacy groups, see: United Mitochondrial Disease Foundation, www. umdf.org and mito action, www.mitoaction.org 7

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Interruptions Receiving a diagnosis of a deteriorating muscular disease changes one’s life. Potsdam, NY, can be a difficult place for healthy people to live. Isolated and rural, the winter temperatures can drop to minus 30 degrees for weeks at a time. The closest academic medical center is three hours away across Lake Champlain. The prospect of living and working through this condition, pushing a wheelchair through snow, ice, and freezing temperatures was probably unreasonable but also terrifying. Living in such close proximity to the Adirondacks, to the things I loved, hiking, skiing, open water swims and my newest obsession, the annual Lake Placid Ironman Triathlon—but knowing that these would become more and more physically impossible—necessitated a change, a new venue, a new start. A life with different intentions could become something less physically and emotionally harrowing. A year after my diagnosis, I left my position at Clarkson and moved to a university in the American south. Working in a large department with a Ph.D. program promised that I could leave behind the distractions of athletics and outdoor recreation and instead focus on my scholarship, teaching, mentoring graduate students, and creating a legacy of young faculty in the field. The university was building a center for the study of nanotechnology, an emerging technology that we will return to in Chap. 3. As “the humanist” on the team, my role was to provide courses, research, and publications that would address the societal aspects of this emerging technology. I was part of a small team of humanists and social scientists to whom the engineers and scientists anticipated outsourcing the “broader societal impact” sections of their National Science Foundations’ grants leaving them free to conduct their lab work. The intent of this initiative and my experiences as a participant were largely similar to what Paul Rabinow recounts about his participation as a much more experienced and qualified primary investigator within the SynBERC center at the University of California Berkeley.9 To foreshadow a theme picked up in Chap. 4, Rabinow writes, “Despite three years of efforts to find some kind of middle ground between what is eerily familiar from C.P. Snow’s  Rabinow, Paul. 2011. The Accompaniment. Chicago: University of Chicago Press, 105–107.

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Two Cultures, it basically never happened.”10 Rabinow writes that he and his colleagues were “consistently treated with indifference” or worse “belligerence.”11 He writes, We were reminded on myriad occasions of our unequal and inferior status, of who was paying for our work, and what the biologists and engineers took to be our arcane words and thoughts. This American Babbitry was especially irritating because basically none of the biologists with whom we worked were personally especially belligerent. Something else was taking place; I came to conclude that we were simply not contemporaries.12

Rabinow’s accounts, and my own experiences in what was a remarkably similar situation, further layered my concern and interest in intention.13 Chapter 4 builds from Rabinow’s concepts of contemporaries and reconstruction, positing these concepts within the activities of intention and research motivation. Contrasting accounts about the emergence of new sciences, scientific research, and research writing in the humanities, the chapter suggests that the dual concepts intention and deliberate action appear to be key spaces within and apart from Modernity that build incommensurability across disciplines. As Rabinow acutely notes, John Dewey in his 1948 Reconstruction in Philosophy perceptively forecasted many of the current difficulties faced by humanities scholars attempting to create interfaces with the sciences.14 Dewey was writing in a particularly similar academic climate, in which, according to Rabinow, “the technical accomplishments of the sciences were expanding while separating themselves ever more from the older moral base in which it was held  Rabinow, 2011, 106.  Rabinow, 2011, 107. 12  Rabinow, 2011, 107. 13  Herndl poses a related problem that similarly engages with intention in interdisciplinary work with STEM researchers. He writes, “My own experience working on interdisciplinary research teams in science is that it is very easy for the rhetorician to ‘go native’ when he or she is the only rhetorican or humanities scholar on a project. It is easy to adopt the intellectual, ideological, and institutional position that typically dominates a scientific research question” (Herndl, 2017, 8). 14  Rabinow, 2011, 174–75. Situating the problem within the humanities is deliberate here as the sciences and engineering disciplines do not recognize anything particularly distressful in the current disciplinary arrangements of work or resource distribution. 10 11

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they used to be embedded.”15 Dewey’s concern, and it is a concern echoed by Rabinow, was that as science and engineering produced new accomplishments, methods, and products, those concerned about the human dynamics and implications of these accomplishments did not produce similarly innovative or new tools. Rabinow writes: Dewey was annoyed at those who advocate that technoscience simply needs a counterweight and that all that is necessary is to institute ethics alongside science. Such a position, he argued, constituted a serious scientific and ethical evasion because it assumed that the necessary ethical responses were already available and only needed to be applied to the new and ever more powerful means that were being invented. The pragmatic difficulties of accomplishing this feat were simply ignored.16

Rabinow cautions that such an “evasion” is evident today; he argues that we are using “the wrong tools for the wrong job.”17

Intentional Action: Tools and Equipment I found Rabinow’s complaint about the wrong tools nicely summarized my experiences. Without the right tools, I could not fully understand what was happening to me physically and I suspected that the lack of these same tools inhibited a productive professional relationship with my colleagues in science and engineering. The problem here was not necessarily knowledge; textbooks, websites, scientific articles, and journals had made the knowledge of science relatively easy to access. Having the resources and connections of a large academic medical center allowed me to pursue my diagnosis in ways not typically available for most patients. I took a course in microbiology at my new university, attended lectures, read journals, and actively sought-out colleagues with research experience in this area. For example, a well-meaning physician suggested I try what was then a relatively new and quite expensive supplement CoQ10  Rabinow, 174–75.  Rabinow, 175–176. 17  Rabinow, 2003, 29. 15 16

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(Coenzime Q10). However, given my expanding knowledge and resources, I was able to recognize that since my deficit was diagnosed at the cytochrome C sequence (rather than Q) the supplement would do me little good. Instead, I started taking biotin because it is an excellent electron receptor and as a microbiologist colleague said, biotin is like a big sponge that cleans up free radicals. Other researchers whose work I followed reported that exercise has shown excellent results in patients with some forms of mitochondrial dysfunction.18 As the theory goes, exercise generates more mitochondria. My own muscle biopsy showed that I had a “proliferation” of mitochondria in my muscle cells, which the neurologist reasoned made up for the defective ones. The assumption is that this proliferation has occurred as a way to produce extra energy because of the demands during exercise. By continuing to exercise, I reasoned, I create more mitochondria. Further research informed me that apparently mitochondria have about a three-day lifecycle. So I began to hit the gym. Hard. While I had always been an endurance athlete, I reasoned that by building muscle strength, I could build up a reservoir of muscle that would take longer to deplete. I purchased monthly issues of Muscle and Fitness magazine, created catalogues of workouts, and cycled through my days: chest, legs, arms, back, core. I resumed drinking coffee (caffeine is a stimulant and helps with muscle repair 19) and I ate a lot of protein. I intentionally limited carbohydrates and sugars reasoning that these were largely wasted. 20 Rather than three square meals, I would graze throughout the day—small amounts of protein, and fat at regular intervals. Professionally, early in the second year at my new, intentional career, the university’s higher administration became embroiled in a scandal that forced the resignation of the university’s chancellor, provost, and chair of  Taivassalo, Tanja and Ronald G. Haller. 2005. Exercise and training in mitochondrial myopathies. Medicine and Science in Sports and Exercise. 37: 20942–101. See also Taivassalo T. and R.G. Haller. 2004. Implications of exercise training in mtDNA defects—use it or lose it? Biochimica et Biophysica Acta. 1659: 221–31; Murphy, Julie L., et al. 2008. Resistance training in patients with single, large-scale deletions of mitochondrial DNA. Brain 131: 2832–40. 19  American Physiological Society. 2008. Post-exercise caffeine helps muscles refuel. ScienceDaily. www.sciencedaily.com/releases/2008/07/080701083456.htm. Accessed June 18, 2015. 20  Ahola-Erkkila, Sofia, et al. 2010. Ketogenic diet slows down mitochondrial myopathy progression in mice. Human Molecular. Genetics 19: 1974–1984. 18

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the board of trustees.21 These resignations were followed by the university’s vice president for research and my college’s dean and associate dean for research. I did not know whether these subsequent resignations were tied to the first. Along with these high-level resignations came the end of the societal impacts endeavor as it was designed, sponsored, and promoted by the very same people who were no longer in charge. The initiative had gotten off to a bumpy start anyway, while our first proposal with the mechanical engineers had been funded, as soon as the money arrived on campus the societal dynamics team was cut from the budget and the money transferred to engineering equipment. Not having any strong connection to the university, the state, or these new problems, nor, I felt, any particular reason to intentionally forge such connections, I moved back to Potsdam where my partner had a standing offer to return to her position as Vice President of Corporate Communications at the local hospital.

Metrics, Analytics, Intention Three years post-diagnosis, I left my tenured position as a full professor and joined my local community hospital as a project developer.22 Our efforts here to build a process improvement department, implement clinical and operational metrics, and develop a quantitative discourse that helped us to understand the hospital’s day-to-day functions informed and are discussed in Chaps. 5 and 6. The vague job title was probably ill conceived. A short recap: My intention in using autobiography to frame this introduction is to highlight how my own intentions to accommodate a particular medical diagnosis resulted in specific physical, personal, and  For discussion, see Price, Jay and Andrew Curliss. 2008. N.C. State fires Mary Easley as scandal erupts. Raleigh News and Observer, June 8. at http://www.mcclatchydc.com/2009/06/08/69687/ nc-state-fires-mary-easley-as.html. Accessed 15 June 2015; Bowens, Dan. 2008. N.C. State provost resigns over Easley hiring. WRAL.com: http://www.wral.com/news/local/story/5145960/. Accessed: 15 June 2015. Dean Smith provides a synopsis and discussion in Smith, Dean. 2015. Authority in Higher Education. London: Rowman & Littlefield, 205–208. 22  Though obvious to some readers, I have chosen to elide the names of these locations because their identities are incidental to the narrative purpose. For those wishing textual validation, please contact me off line. 21

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professional choices. These actions, while perhaps extreme, were deliberate. I recognize that in the broader scope of things, a medical diagnosis that necessitates regular vigorous exercise and yoghurt covered peanuts is a privileged burden. Stepping aside, what is more problematic here in retrospect is the floundering and chasing that accompanied what could have been a relatively well-managed and low-key occasion. Certainly ­timing was an issue. Shortly after my diagnosis, the diagnosing physician retired and the only referral he made was an immediate appointment with a Muscular Dystrophy fundraiser in his office (who fortunately accepted credit cards). My academic background, access to the scientific literature, and rarity of the condition meant that I had more knowledge on hand than most physicians I consulted. In addition, I did not appear sick. My regimen was showing success, I gained 20 pounds and could bench press 225—the magic number at which one has started to become serious. In theoretical terms, I suspect that a good deal of what I perceived as problematic here resulted from an inability to know how to exteriorize intentions, how to get from here to there, equally physically, emotionally, and professionally. The complication was more structured and deliberate than desire, but no less obsessive. Lyon posits that intention differs from desire in that intention is a state of mind “with a distinctive role leading to planning, a role not shared with desires and beliefs.”23 Noting problems related to causality and empirical validity, she writes that seeing desire and intention as linked but still separate is useful for articulating the “complex knot” the concepts construct. She writes, In this view, while desire precedes intention and action and is not the sole force behind intention, both desire and intention seem forward looking (bathed in longing or loathing), both arise in our needs for control and change, and both can be signified consciously and unconsciously, but intention is the mental state that executes belief and desire. Intention presumes desire.24

23 24

 Lyon, 145.  Lyon, 145, emphasis in original.

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Desire, emerging from a lack that must be fulfilled, requires something else to enable intention, something to both anchor that realization and spark an achievement process. Here, desire is potential while intention is actionable.25 Managing a disease would seem to be an effort to operationalize desire, an intentional effort. And yet, a disease complicates planning and execution because of the way perception and activity are restlessly oriented to short-term goals and daily functioning. What becomes important shifts and slides as dysfunction seeps into cognitive spaces not attuned for a lack of attention. Spaces for relationships, work, planning, diplomacy, or enjoyment orient toward phantoms real and imagined. Negotiating with my new employer was quick and largely indifferent. I inserted a line in my contract that stated I could take time to exercise everyday “for medical reasons.” In the third volume of this History of Sexuality, Foucault outlined the deep inheritance Western concepts of “self-care” owe to Classical thinking. Citing a passage from Socrates, Foucault notes how the Greeks tied military, political, and legal success firstly to self-care. He writes, Socrates shows the ambitious young man that it is quite presumptuous of him to want to take charge of the city, manage its affairs, and enter into competition with the Kings of Sparta or the rulers of Persia, if he has not first learned that which it is necessary to know in order to govern: he must first attend to himself.26

While this concept focused primarily on the soul, Foucault notes that self-care was also intimately correlated with the medical self such that it was possible to equate physical sickness and philosophical distress. Foucault writes of “a grid of analysis that was valid for the ailments of the body and the soul.”27 As part of this grid, Foucault notes were “sick persons who are cured of all of part of their vices and those who are rid of their ills but not yet rid of their affections; and there are those who have  Lyon146–147.  Foucault, Michel. 1988. The History of Sexuality Volume 3: The Care of the Self. Translated by Robert Hurley. New York: Vintage Books, 44. Originally published as: Le souci de soi. Editions Gallimard, 1984. 27  Foucault, 1988, 54. 25 26

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recovered their health but are still frail because their predispositions have not been corrected.”28 In this regime, the physical determents of the body have direct influence on the soul, and those “bad habits of the soul” can manifest themselves in physical illness. Chapter 5 pursues this narrative in an admittedly critical examination of intention in medical practice. While a stated goal of my project is to move beyond retrospective critique, there are still times when critique can play an important and useful role. The experiment played out in Chap. 5 is whether intention can be used as a device for critical assessment, as a way to disentangle and understand human motives from non-­ personal, systemic actions. Working from Kenneth Burke’s dramatism the chapter examines how intention overlays medical acts, agents, scenes, and purposes. By reviewing Burke’s early discussions of “directed intention” in Pascal’s letter and his later articulation of terministic screens, the chapter uses intention as a heuristic device to ask why a particular activity becomes prominent within a system and what those activities can tell us about that system. By examining human motivation (heroism), reform efforts and the role of primary and preventative care (metrics, quality improvement, specialty alignment), the increasing divide between the patient’s and the physician’s expectations in medical care, and lastly the imposition of electronic medical records (HER/EMRs) into health systems, the chapter asks what can intention tell us about the system of American healthcare and what can the system of American healthcare tell us about intention? Incentives built into the American Recovery and Reinvestment Act (ARRA) have meant that health systems are quickly updating electronic medical systems to comply with Centers for Medicare and Medicaid Services’ (CMS) “meaningful use” requirements. While some of the more advanced electronic systems provide analytical capacities for assessing productivity, performance, quality, and finance, most health care organizations have now learned that simply installing a new computer system will not transform a hospital into an information-driven culture. Obstacles persist in the ways that an information-driven culture threatens existing experience and tradition-based hierarchies. Hospitals have strong 28

 Foucault, 1988, 54–55.

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and protective administrative and cultural silos in which information reports vertically with few opportunities for sideways integration. 29 Finance typically is bracketed from clinical practice; and quality performance improvement, case management, or other areas of administrative oversight have few points of leverage within clinical areas. Further, medical data is highly restricted and its use regulated by federal Health Insurance Portability and Accountability Act (1996). Simultaneous to these hospital-level initiatives and problems, the U.S.  Department of Health & Human Services has now made available Medicare quality, performance, and cost data of hospitals, physicians, nursing homes, home health agencies, and dialysis facilities.30 The hospital-specific site allows visitors to compare hospitals’ process of care measures, outcomes, use of medical imaging, patients’ experience, patient safety, volume, and overall Medicare spending. Hospitals can be compared on general characteristics, specific diseases, and specific surgical procedures. As the chapter discusses, what becomes problematic here is the way these metrics orient intentions in ways that may have little value to patients, physicians, or actually desired healthcare outcomes. The hospital I joined had recently recruited a new CEO, a brilliant logistical and strategic thinker. My first project was to gain access to daily operational data across the hospital to enable him to know what was going on. At the time, the hospital would receive reports at 6-month intervals reporting admissions, discharges, and various metrics. His concern was that by the time he received the data the information was useless. This effort occurred simultaneously as analytics and the larger project “big data” was emerging with consequence in business schools, literature, and even popular culture. Well-publicized and controversial examples included case studies from retail stores, sports, and politics. In a now well-publicized example, retail company Target used customer data  Berger, Scott. 2005. The Power of Clinical and Financial Metrics. Chicago: ACHE Management Series, Health Administration Press; Dlugacz, Yosef. Andrea Restifo, and Alice. Greenwood. 2004. The Quality Handbook for Health Care Organizations. San Francisco, CA: Jossey-Bass, 44; Becker’s Hospital Review. 2012. Breaking down silos to improve patient flow, hospital efficiency. DOI = http://beckershospitalreview.com/capacity-management/breaking-down-silos-to-improve-patientflow-hospital-efficiency.html 30  For details see: http://www.healthcare.gov/compare 29

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mining to predict if women customers were newly pregnant. Customers who met the specific data profile were sent coupon books with pregnancy and baby products. 31 Analytics is primarily concerned with transforming raw, unstructured data into quantitative forms that can be mined, interpreted, and validated. Davenport and Harris, early advocates of the field’s business applications, define analytics as “the extensive use of data, statistical and quantitative analysis, explanatory and predictive models, and fact-based management to drive decisions and actions.”32 Advocates claim that such empirical data can inform and drive understandings of complex systems and ultimately enable better evidence-based decisions. Professional sports have probably done more to popularize analytics than any other industry, specifically Major League Baseball and Oakland Athletics manager Billy Beane. Beane’s analytics-based coaching methods led to a full reassessment of baseball strategy, recruiting, and the metrics used to interpret the game. Beane’s approach became known as Sabermetrics and has been the subject of numerous profiles and most famously the subject of the book and movie Moneyball. 33 The Massachusetts Institute of Technology’s Sloan School of Business has a yearly conference investigating analytics and athletics and ESPN The Magazine produces a yearly analytics issue. 34 In politics, data analysts have taken notice of the 2012 Democratic

 Duhigg, Charles. 2012. How companies learn your secrets. New York Times, Feb 16. http://www. nytimes.com/2012/02/19/magazine/shopping-habits.html?pagewanted=all. The controversial aspect of this practice was highlighted not so much as the data surveillance story as the story of a distraught father who accosted a Target manager for pregnancy coupons the store had sent to his teenaged daughter. The manager apologized only to receive, several days later, his own apology from the father who subsequently learned that his daughter was indeed pregnant. See, Hill, Kashmir. 2012. How Target figured out a teen girl was pregnant before her father did. Forbes Magazine, Feb 16. http://www.forbes.com/sites/kashmirhill/2012/02/16/how-target-figured-outa-­teen-girl-was-pregnant-before-her-father-did/. Accessed 18 June 2015. 32  Davenport, Thomas and Jeanne Harris. 2007. Competing on Analytics: The New Science of Winning, Cambridge MA: Harvard Business Press, 7. 33  Lewis, Michael. 2004. MoneyBall: The art of winning an unfair game. New York: W.W. Norton. The 2011 movie, MoneyBall was produced by Brad Pitt, Micheal De Luca, Rachel Horovitz and Directed by Bennett Miller. 34  For the MIT analytics and sports conference, see: http://www.sloansportsconference.com/; also see, http://espnmediazone.com/us/press-releases/2013/02/espn-the-magazine-analytics-issue-onnewsstands-friday/ 31

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Presidential campaign for extraordinarily successful demographic data segmentation and predictive modeling. 35 Chapter 6 emerges from my hospital-based immersion in the world of business analytics situating this work within the rhetorical canon as a post-intentional heuristics. The chapter examines “electronic heuristics” to refer to software-based structured data mining tools. These digital systems have made the extraction, reporting, and quick interpretation of large data sets relatively simple and widely available making large domains of information transparent and easily accessible. These tools have also provided a technology for intention in data mining and the large-scale assessment of qualitative factors influencing human endeavors. Specifically, our work at the hospital moved from reporting descriptive information to more strategic, complex, and contentious work using these data for direct and immediate process improvement projects. Projects ranged from small, “in the weeds” assignments like ensuring each patient’s primary care provider was documented during registration to a large-scale renovation of the entire Emergency Department and the creation and implementation of a complex, multi-faceted, 6-month Perioperative Services (surgery) business plan. The projects discussed in Chap. 5 are more micro in scale and involve the direct movement from granular data gathering to process changes. Rhetorically, the chapter furthers the book’s narrative arc from the retrospective analysis of intention and the temporal debates during which intention has been contested to potential equipment for overtly embedding intention into equipment for analysis and writing. What struck me about the relatively new pursuit for a process improvement science was the extent to which these projects suggest the potential for a more active awareness and deployment of intention within rhetorical heuristics. What has been overlooked in the overarching discourses incorporating big data, analytics, and process improvement has been the necessary role  In 2012, Democratic campaign data analysts were able to predict inclination to donate to the campaign, likelihood to vote, and the ability of specific advertisements to generate action within very specific and precise demographic subsets. See: Scherer, Michael. 2012. Inside the secret world of the data crunchers who helped Obama win.” Time, Nov 7. http://swampland.time. com/2012/11/07/inside-the-secret-world-of-quants-and-data-crunchers-who-helped-obamawin/?hpt=hp_t2 35

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for strong rhetorical talents. Analytics certainly requires strong quantitative skills for statistical analysis and model building but such mathematical talent requires insightful social knowledge for building organizational concepts and forms, and exceptional narrative abilities for designing meaningful and persuasive accounts. As such, process improvement is interwoven with innovation, creativity, and, as the chapter poses, discourses of intention. This later work became a focus of my current work, having returned to a career as an academic researcher and teacher in Worcester, Massachusetts. Three years after returning to Potsdam I was offered the opportunity to help develop humanities courses and project-based learning experiences for pre-health students. The opportunity combined my academic and healthcare experiences and I developed courses in healthcare policy, science writing, medical writing, and projects in healthcare analytics and epidemiology. Personally, I knew that none of my original reasons for initially leaving northern New York had changed and the massive academic healthcare infrastructures available in Massachusetts offered state of the art access to neurologists, research, and exposure to potential research trials and medical communities. While retaining a consulting role at the hospital I moved (again) to Worcester, Massachusetts, and began to search for a neurologist who specialized in metabolism, ideally mitochondrial diseases. While the studies and texts that influenced the early debates about intention emerged from literary studies their import has not been isolated from other forms of textual study. Yet, as Thomas Huckin, whose work on textual silences informs Chap. 7, has persuasively shown, experts in linguistics and language philosophy were not as quick to abandon intention. “Ordinary language philosophers, such as Austin, Searle, and Grice,” Huckin has written, “have long shown that a listener’s uptake depends greatly on what he or she perceives to be the speaker’s communicative intent.”36 This linguistic history informs the next chapter and is picked up again in Chap. 7. Huckin argues that at least in the case of textual silences, “the perception of intentionality in such cases is a  Huckin, Thomas. 2002. Textual silence and the discourse of homelessness. Discourse & Society 13(3): 347–372, 366. 36

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p­ rerequisite for interpretation.”37 Yet Huckin’s analysis also calls for a greater attention to ethics and intention in discursive practices. Huckin introduces the intriguing concept of dispersed intention to describe institutional practices (like newspaper editorials) that evoke particular ideologies that do not appear to be isolated to particular writers but emerge from larger commercial and organizational convergences. Working from Huckin’s examination of textual silences as well as other examples from medical and legal discourses, the concluding chapter introduces the concept of discursive curations. Discursive curations are strategic, temporary, and context-specific aggregations of discourse and structure that are designed to achieve a particular intent. The chapter argues that unlike other discursive aggregations (genre, hybridity, interdiscursivity) curations are unique because they are temporary and context-­dependent and the intent driving a curation is in isolation from, without influence on, and even discordant to, the discursive or social exigencies of the curation’s constituent parts. The chapter then turns explicitly to professional discourses and the ethical questions curations raise for intention in professional discourse. The chapter concludes by arguing that while intention may be unnecessary or unavailable in some forms of textual study, intention is a formative and defining component of professional discourses. Thus, intention is central to professional discourse and by association, professional activities. The book argues that intention can be a useful component of interpretive, descriptive, and enactive discourse. Intention may be unknown, unavailable, or masked but asking about and inquiring into intention may help to ground discursive activity and may help us to better understand human and institutional action. Intention may help us to better understand and simultaneously differentiate empathy and disingenuousness, failure and gaming, effort and opportunism. The Postscript, written toward the end of the COVID-19 pandemic, updates the book’s narrative, discusses the role intention played in my experiences as paramedic during COVID-19, the way intention informed and derailed public health and science communication during the pandemic, and investigates further ways to develop an intentional humanities practice.  Huckin, 366.

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After a year in Worcester, I located a local expert at the University of Massachusetts Medical School who specialized in muscular dystrophies and mitochondrial disease. After several lengthy email exchanges in which we discussed my diagnosis and some of the newer sciences associated with the disease,38 the physician agreed to see me for a consult and potentially regularly follow my progress. Three moves and three jobs, dozens of scientific journal articles, hours spent deciphering medical websites and books, a course in microbiology, a new diet, new exercises, 20 additional pounds, new teaching assignments, and new research fields had produced an intentionally new me. In year eight after my diagnosis I met my new neurologist. Studying my history, biopsy results, lab tests, and his own examination notes, he turned to me and said, “I’m not entirely sure what is going on here, but I do know that whatever it is, you do not have a mitochondrial disease.”

 Again, an admitted privilege of a dot edu email address and the access an academic institution provides. 38

2 Signaling and Framing, From Interpretation to Production

…all knowledge involves experimentation, with whatever appliances are suited to the problem in hand, of an active and physical type –John Dewey (Dewey, John. 2004 Essays in Experimental Logic, Mineola, New York: Dover Publications, 279. Original edition: Dewey, John. 1954. Essays in Experimental Logic. University of Chicago Press, Chicago IL)

This project is about intention and textual studies. Nested in this semaphoric claim are a number of assumptions that require some unpacking. My own intention in embarking on this project was not to develop a defense of intention as a tool of textual studies, nor will this book build a grand theory for reinstating intention within the rhetorical canon. There are a number of reasons for this. Most importantly, as this chapter will show, such work has already been done and need not be repeated. In the examples and literature described below are robust and comprehensive examinations of intention that appropriately situate the term as a key component across the many

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 B. Faber, The End of Genre, Postdisciplinary Studies in Discourse, https://doi.org/10.1007/978-3-031-08747-9_2

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fields that make up textual studies.1 This is not to claim that intention has received routine attention in textual studies. As this chapter will show, the topic appears oddly cyclical with attention increasing for short bursts and then waning. Intention is not a new topic in rhetoric, discourse studies, pragmatics, or critical discourse analysis but those who have explored the topic contend it is central to any understanding of language-in-use. Thus, while the literature here is deep and robust, it has not been durable. Some of this mixed attention may be because intention has been a problematic subject for textual studies. As Arabella Lyon writes, “even the most familiar practices of intending can paradoxically be difficult to recognize: we can recognize what is familiar, but if it is too familiar, we tend to overlook it, see it as self-evident, and may not even know how we recognize it.”2 Or, as G.E.M. Anscombe writes, intention carries the popular misconception that “if we want to know a [person’s] intentions, it is into the contents of [that person’s] mind, and only into these that we must inquire.” As a result, it is easy to dismiss intention as something empirically unattainable, something “whose existence is purely in the sphere of the mind” Anscombe cautions.3 Rhetoric, unlike philosophy or psychology, is typically less concerned with the “sphere of the mind” and more interested in persuasion. .4 Intention undoubtedly contributes to persuasion or may be evidence of persuasion, but unlike audience, purpose, and context, intention can be much more ephemeral, hidden, and resistant to empirical inquiry. Woodward puts it this way,  Lyon, Arabella 1998. Intentions: Negotiated, Contested, and Ignored State College, PA. Woodward, Gary. 2013. The Rhetoric of Intention in Human Affairs. Plymouth UK: Lexington Books. Lyon writes, “In effect, the complexity of authorial intentions and of interpretation’s dependence on historical situations (including those of the author and reader) guarantees that literary critics and literary rhetoricians will continue to discuss the concept of intention in critical enterprises, even if they have to live with the uncertainty of interpretation and be less concerned with the concept’s use in assessing aesthetic value or with the valorization of individual author’s lives,” 28. 2  Lyon, 185. 3  Anscombe, G.E.M. 1963. Intention. Cambridge MA: Harvard University Press, 9. Original edition: Anscombe, G.E.M. 1957. Intention. Oxford: Blackwell 1963. 4  The study of persuasion necessarily has a cognitive/psychological component and the overlapping influences of language and psychology are relevant for studies of intention. On this history, see especially, Sperber, Dan and Deirdre Wilson. 2005. Pragmatics. In Oxford Handbook of Philosophy of Language, ed. Frank Jackson and Michael Smth. Oxford: Oxford University Press. https://www. dan.sperber.fr/?p=117; Sperber Dan and Deirdre Wilson. 1981. Pragmatics. Cognition 10: 281–286. For contemporary examination of cognition, perception, and intention, see Searle, John R. 2015. Seeing Things as they are: A Theory of Perception. Oxford: Oxford University Press. 1

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If the idea of determining ‘authorial intent’ is now passé in literary analysis, it remains the de-facto presumption that governs our search for practical guidance about others. While it poses immense epistemological problems (i.e., “how do we know what we know?”), it positively invites rhetorical analysis, which searches more for shared understanding than the verification of results.5

This chapter takes a step back from my engagement and experiments with intention to cover some preliminary ground at the intersections of intention and rhetoric, textual linguistics, discourse studies, and critical discourse analysis. With apologies for those who prefer more subtle distinctions, I have aligned these fields under the shorthand “textual studies” as they all address written texts, the primary subject of my project. In what follows, this chapter will outline foundational work about intention in textual studies and then introduce the concept of experiments with intention that guide subsequent chapters. By using the term experimentation I introduce a second theme that also informs the book which is the relationship between the academic humanities and those disciplines now commonly referred to as STEM, an acronym that includes disciplines in the life, physical, health, and computer sciences, engineering, and mathematics.6 As narrated in the previous chapter, my experiences in healthcare both introduced me to scientific disciplines where research was designed and intended to be used for problem solving and demonstrated to me the extent to which my own humanities training seemed unprepared for such challenges. Central to this concern is the way STEM disciplines deploy intention as a motivational and ethical concept. The more I worked within these sites the more I realized that my own academic practices required a concomitant discourse of intention if I hoped to collaborate with colleagues in these more applied fields. Experimentation refers to my attempts to develop a more productive form of textual scholarship in the humanities and to the question what might an “intentional humanities” look like in textual studies. This chapter does not solve these questions but responds to requests by early manuscript  Woodward, xii.  Some describe the acronym as Science, Technology, Engineering, and Mathematics, others substitute Medicine for Mathematics. Given the amount of grant money and student enrollments associated with STEM programs, aligning one’s discipline within the acronym becomes a highly intentional act. 5 6

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reviewers for a more comprehensive accounting of how intention has been addressed in textual studies and what I intended to accomplish in the chapters that follow. These requests deploy an aggregation that forms a further theme throughout the book which is how intention is not only studied as a topic within textual studies but also the extent to which scholars in our field are transparent about the intentions for their work. As I will discuss below, critics of various forms of textual scholarship have not been kind about the lack of productive work across the field. Textual studies has been synonymous with retrospective critique and while our various disciplines have aligned their scholarship with social changes that would improve people’s lives, textual scholarship seems to continue to emphasize descriptive critique over positive action. A discourse of intention refers to both a way to methodologically examine intention as a topic of textual study and a more deliberate acknowledgment and awareness of a researcher’s own intentions as a productive motivation when conducting textual research.

Intention in Rhetorical and Textual Studies Corners of rhetoric and textual studies, especially those marked more heavily by computer science and psychology, have had a more durable use for intention.7 These approaches have productively informed technical applications in the field such as information architecture, interface design,  See, for example, Wallace, David 1996. From intentions to text: Articulating initial intentions for writing. Research in the Teaching of English 30: 182–219. Here, Wallace showed that students “who are able to articulate useful initial intentions” wrote more effective texts and were better judges of effective writing than students whose intentions suggested they did not understand the terms of the assignment (186; 197). For Wallace, the concept of intention was pragmatic and useful intentions consisted of a student detailing in an interview how to meet the criteria for an assignment. This articulation necessitated both the information that needed to be included in an assignment and “how that information could be used for rhetorical purposes” (186). Wallace’s study echoes earlier studies conducted by Linda Flower and John Hayes who developed a cognitive process theory for studying writing. Using talk-aloud and other protocols, the work attempted to detail what writers were thinking while they wrote. The theory argued, in part, that composing is a “goal-directed thinking process” that is “guided by the writer’s own growing network of goals,” that these goals are created to “embody a purpose” but the goals can change if learning suggests alternative goals (366). Intention here, as Wallace deploys in his own study, refers to how a student expects to fulfill the assignment, or in other words, how the student anticipates fulfilling the goal. See, Flower, Linda and John R.  Hayes. 1981. A cognitive process theory of writing. College Composition and Communication 32: 365–387. 7

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and user experience. But in doing so, they have perhaps necessarily departed from a humanities-based enterprise and an interest in the contradictions, situatedness, and heterogeneity that complicates human activity in favor of a narrower and utilitarian detent with intention. While elements of this book are drawn from such technical approaches, and are admittedly jealous of their influence on professional practices, my interest in this project has been to explore how the concept of intention can build a more complex understanding of discourse and action, one that retains the contradictions and richness that make us (at times frustratingly) human. How such a project might settle out remains undefined, a loose end that one book alone should not attempt to solve. Lyon’s assessment of intention’s more instrumental function in rhetorical scholarship emerged from a disciplinary context in which rhetoric was still tightly bound to literary studies. This may be a more North American conceit as internationally discourse studies has been less institutionally tied to English departments. But, given my own geographical location as a scholar educated in Canada and the United States, I have taken Lyon’s context as the starting place for my project.8 “The concept of intention found in contemporary rhetorical theory,” she writes, “unfortunately is much more like that of literary criticism, which focuses on authorial intention in relationship to the interpretation of a text and the evaluation of the significance—meaning and worth—of art.”9 Lyon persuasively rights these wrongs, showing that intention, in various forms, has been a central, if at times a strangely unmarked, concept within rhetorical scholarship. Lyon situates intention as a key rhetorical concept that synthesizes Kenneth Burke’s terms form or structure, motive, and purpose.10 As Lyon writes, “[t]he multiplicity of terms and the different perspectives they offer on instrumental language and human agency allow Burke to give intention a very complex analysis and position in rhetorical discourse.”11  I also admit that my focus is on Western discourse studies and approaches to intention. For a more cross-cultural approach, see Duranti, Alessandro. 2015. The Anthropology of Intentions: Language in a World of Others. Cambridge: Cambridge University Press. 9  Lyon, 9. 10  Lyon, 86. 11  Lyon, 86 8

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As Lyon shows, Burke’s interest in intention is woven throughout his dramatistic model and intention is a central problem, in the productive sense of the term, for his dramatistic ratios. Intention is not overtly motive, purpose, act, or activity, but is found in the interaction of these terms. Intention is clustered with ambiguity, transcendental, paradox, and compulsion (or desire).12 Such lexical slipperiness and irreducibility make intention difficult to define and conceptually locate as an empirical locus. This of course is not a new contribution to our understanding of intention but suggests a caution for readers of this book expecting an uncomplicated disentanglement of the term. Like Lyon, Gary Woodward’s approach to intention is dramatistic and also emerges from Burke’s work on motives. Woodward’s account is also variable, “We may desire clarity in sorting out the motives of one person from another” he writes, “but it is evident that one cause cannot be easily disentangled from others.”13 Woodward’s understanding of intention seems similar to Anscombe’s, “Getting a fix on the ‘why’ of human action—even if illusory—is often of more consequence than the action itself ” he writes.14 But unlike Anscombe, Woodward argues that intention marks a more subjective than factual set of discourses. Rather than attempt to define intention, Woodward chose to show how intention mediates human deliberation and action and he provides an Aristotelian template of how intention is used in deliberation and as a way to explain action. In addition to actual motivations, he shows that intention can (and more often does) derive from fantasy and the generative power of what he calls “imagined action,” that “a community’s shared fantasies can hold significant sway over the individual.”15 Woodward’s treatment is prescient, especially as he highlights the importance that fantasy, groupthink, and collective narratives have on individual motives. In his chapters on conspiracy theories; theater, acting, and performance (both on stage and off); journalism and the presentation of motives in news stories; legal rhetoric; and the theology of divine  see Lyon’s discussion, 98–101.  Woodward, xii. 14  Woodward, 7. 15  Woodward, 3, emphasis in original. 12 13

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intervention, Woodward presents a compelling case for locating intention firmly within rhetoric’s dramatistic approaches. Parsing intentional claims as references to “internal states, external states, a role template, and a model of moral worth” he shows four unique but often overlapping ways intention is deployed as a retrospective explanation for self (and other’s) behavior.16 In full deference to those who knew better, a decade ago I embarked on this project naively anticipating a more fixed and settled final account. But in the subsequent effort, I came to realize that intention is a much more ephemeral concept; in as much as intention is influential, motivational, productive, it resists definition and fixation. Yet, what Lyon and Woodward show in their different tracings of Burke’s dramatism is that intention necessarily permeates rhetorical scholarship in a physical way. Working from Wittgenstein, Lyon argues “There is a basic physicality to our recognition of intentions.” She continues, “We not only assume intentions and attribute intentions to others, but we recognize intentions through our senses’ reception of physical signs. We see the smile, his eyes shift, the larger print, the subheading. We hear the voice get softer, the tone duller, the too-subtle nuance of argument. We smell the sweat, feel the quality of the stationary, the speaker’s hand upon us. Logos, ethos, and pathos are performed.”17 In other words, intentions, while of the mind, are also of the body. “[I]ntention issues in actions” Anscombe writes, “what physically takes place, i.e. what a [person] actually does, is the very last thing we need to consider in our enquiry. Whereas I wish to say that it is the first.”18 Following Lyon and Woodward, the chapters that follow emerged as multilayered and self-reflective investigations into spaces where action and motivation appeared to intersect: a narrative blending of activity and observation, reflection and anecdote, precedent and ambiguity. Here, I take intention’s relevance for rhetoric as a settled issue and instead seek to experiment with intention’s utility as a tool for an alternative project of human-centered inquiry.  Woodward, 8, emphasis in original.  Woodward, 109. 18  Anscombe, 9. 16 17

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Intention in Linguistics and Discourse Studies While intention has held a generative role in linguistics, here too the concept has lacked durability. Brown and Yule see intention as a formative component of conversation, interpretation, and discourse analysis. “The intention of the speaker is not necessarily referential,” they write in a phrase that seems to ground a great deal of future work in discourse studies and critical discourse analysis.19 They argue that intention should be seen as a social concept, that understanding and interpreting intention are a requisite component of maintaining and building relationships and functioning in social settings. Echoing Wittgenstein, they show that intention is tied to context and to situation and thus to form. “When two strangers are standing shivering at a bus-stop in an icy wind and one turns to another and says ‘My goodness, it’s cold,’ it is difficult to suppose that the primary intention of the speaker is to convey information” they write.20 Instead, they offer that the speaker “is indicating a readiness to be friendly and to talk.”21 In this way, registering intent is a daily, if complicated, component of communication and social interaction. In a discussion that we will revisit in Chap. 3, Brown and Yule note that intention is not only linked to social context, but is a constituent part of linguistic form. Speakers can use various paralinguistic forms to ensure that what they have said matches their intentions while writers can use headers, fonts, titles, and even lineation to demonstrate intent. For Brown and Yule, the discursive forms implicature and inference are reliant on intention, as are insults, the differences between attribution and referential language, and the interpretation of form itself. They write, “The work of those seventeenth-century poets who created poems in the shape of diamonds or butterflies would be largely incomprehensible if the form were not preserved.”22 More granularly, they argue that intention is enfolded even within grammatical forms. When reading, “[w]e seek to  Brown, Gillian and George Yule. 1983. Discourse Analysis. Cambridge: Cambridge University Press, 211. 20  Brown and Yule, 3. 21  Brown and Yule, 3. 22  Brown and Yule, 7. 19

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identify the writer’s intended referent for a pronoun, since a pronoun can, in effect, be used to refer to almost anything.”23 Of course, those seeking alternative interpretations can use the polysemy of pronouns and prepositions to misconstrue or elicit alternative interpretations. Brown and Yule are perhaps too gracious in their characterization of interpretation, writing, “what the textual record means is determined by our interpretation of what the producer intended it to mean.”24 Here, they echo Grice’s conversational conventions or maxims, which presume an honest intention of a speaker or writer. As we will examine throughout the experiments of this book, the relationships between intention and interpretation appear to be more doubled, or layered, than Brown and Yule posit. Grice posited that by “flouting” one or more of the maxims, the speaker or writer posits additional meanings in addition, antithetical, or agnostic to the literal meaning of the text. Here, Grice offers some insight into how to recognize an alternative intent or an intention apart from the literal conveyance a text would suppose.25 Perhaps another way to phrase Brown and Yule’s statement could be, what the textual record means is determined by our interpretation and our own intention of what the producer intended to mean. As noted above, intention has been used in psychology and cognitive fields as an interpretive frame to examine how the mind operates. Here, research has posited that language provides direct insight into human thought and has informed a great deal of cognitive work in rhetoric and the philosophy of mind. While not a focus of this book, the tradition demonstrates an alternative use for intention and linguistics. Dan Sperber and Deirdre Wilson have articulated this cognitive inquiry as a more recent branch of pragmatics and discourse studies.26

 Brown and Yule25.  Brown and Yule, 25. 25  Grice, H. Paul. 1975. Logic and conversation. In Syntax and Semantics 3: Speech Acts, ed. Paul Cole and Jerry Morgan, 41–58. New York: Academic Press. For discussion of Grice’s maxims, see Brown and Yule, 31–35. 26  Sperber, Dan and Deirdre Wilson. 2005. Pragmatics In Oxford Handbook of Contemporary Philosophy, ed. Frank Jackson and Michael Smith, 468–504. Oxford: Oxford University Press. Online version https://www.dan.sperber.fr/?p=117. References below from online version. 23 24

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Linguists like Brown and Yule and Stephen Levinson conceptualized pragmatics as the study of inferential meaning. Pragmatics makes a cognitive step beyond semantics, which Sperber and Wilson denote as the study of “decoded meaning.” As Sperber and Wilson explain, much of what gets communicated in speech and writing falls outside of strict, explicit, “truth-conditional content” but relies on pragmatic aggregations.27 This analytical approach was largely enfolded within speech-act theory. “Speech-act theorists,” write Sperber and Wilson, “underlined the fact that a speaker’s meaning should be seen not merely as a set of (asserted) propositions, but as a set of propositions each with a recommended propositional attitude or illocutionary force.”28 Resolving (or creating) gaps between sentence meaning and speaker meaning, or otherwise put, a writer’s intent and a reader’s interpretation, are seen here as not solely linguistic acts but psychological and cognitive. Whether this understanding reinforces context-dependent interpretations of meaning making or more formally aligns linguistics with cognitive psychology or neurology aligns considerable current debate in pragmatics and language theory. As Levinson and later Sperber and Wilson explain, Grice’s work articulated meaning making as a psychological activity in the sense that he claimed that meaning is constructed when the audience recognized the speaker’s intention, “it provides an account of how more can be communicated, in his rather strict sense of non-naturally meant, that what is actually said,” Levinson writes.29 For Grice and others, this recognition occurs cognitively and suggests that communication requires rhetors to affect a psychological recognition that may or may not involve linguistic symbols. As Sperber and Wilson write, “[t]he challenge is precisely to explain how the closed formal system of  Sperber and Wilson list as examples: “illocutionary force indicators, presupposition triggers, indexicals and demonstratives, focusing devices, parentheticals, discourse connectives, argumentative operators, prosody, [and] interjections.” section 6, lines 5–6. 28  Sperber and Wilson section 6, lines 12–13. For foundational texts in speech-act theory, see Austin, John. 1962. How to do things with Words, The William James Lectures delivered at Harvard University in 1955, ed. J.O. Urmson. Oxford: Clarendon Press; Searle, John R. 1969. Speech Acts. Cambridge: Cambridge University Press. 29  Levinson, Stephen. 1983. Pragmatics. Cambridge: Cambridge University Press, 101. 27

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language provides effective pieces of evidence which, combined with further evidence from an open and dynamic context, enable hearers to infer speaker’s meanings. The methods to be used are those of cognitive psychology, including modeling of cognitive processes, experimental tests, studies of communication pathologies (e.g. autism), and evolutionary insights.”30 If intent, and by consequence, meaning, is established cognitively in the minds of a speaker and a listener, the study of language has little value here apart from conveyance. As Sperber and Wilson write, “its main relevance is to cognitive psychology” and the rest would be at best a cautionary tale for future scholars.31

Intention in Interpretation and Performance Yet, take this example from law, a judge who thinks a defendant is guilty receives a “not guilty” verdict from the jury. The judge reads the jury’s finding which declares the defendant not guilty. The judge’s intention is to uphold an oath, preserve faith in the judicial system, and respect the right to a trial by jury. These intentions are apart from the meaning of the declaration “not guilty.” Similarly, an official certifies a wedding certificate endorsing a couple the official does not think should be married. In both cases, the intents of what we can call the “speech act” are multifaceted and in their professional accomplishing their functions are not necessarily linked to immediate psychological cognition. Artificial intelligence and computer-based systems further complicate discursive intention here. When a physician writes the diagnosis “acute upper respiratory infection” the patient is ascribed the diagnosis and the clinic is reimbursed by the computer billing system for ICD10 J09.6 even if the patient is unaware of the diagnosis and no one at the insurance company ever reads the patient chart. More problematically, a bank manager may intend to help a family obtain a mortgage but the computer algorithm

30 31

 Sperber and Wilson, section 7, lines 18–20.  Sperber and Wilson, section 7, line 21.

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that processes the application establishes the family as not qualified for the mortgage.32 These examples are consistent with what John Austin called “performatives.” Austin’s performatives were statements that did not describe or report information, did not rely on truth or falsity, but in their utterance were part of an action (in addition to the action of communicating something). Austin writes, “it seems clear that to utter the sentence (in, of course, the appropriate circumstances) is not to describe my doing of what I should be said in so uttering to be doing or to state that I am doing it: it is to do it.”33 Austin gives the example of naming a ship, “to name a ship is to say (in the appropriate circumstances) the words ‘I name, &c.’.”34 The discursive function and intention here is enactment rather than information exchange. Austin’s model incorporates three simultaneous actions discourses accomplish: locutionary, illocutionary, and perlocutionary acts. Locutionary acts are defined as utterances that the originator intends as meaningful, what Levinson calls “the utterance of a sentence with determinate sense and reference.”35 An illocutionary act, according to Austin, is “performance of an act in saying something as opposed to performance of an act of saying something.”36 Here, Austin refers to the act of raising a question, issuing a warning, announcing a verdict, making a criticism (as opposed to the content of the question, warning, announcement, criticism). The perlocutionary act is the act of producing an effect in an audience. For example a perlocutionary act could produce belief,  See The Marku, 2021. The Secret Bias Hidden in Mortgage-Approval Algorithms. https:// themarku,org/denied/2021/08/25/the-secret-bias-hidden-in-mortgage-approval-algorithms. Accessed 30 Dec 2021. The study found that loan applicants of color were 40%–80% more likely to be denied than identically qualified white applicants. This discrepancy was attributed to a computer algorithm developed by Freddie Mac and Fannie Mae, mortgage companies established by the US federal government to improve homeownership. According to the report, the algorithm is “widely considered detrimental to people of color because it rewards traditional credit, to which White Americans have more access. It doesn’t consider, among other things, on-time payments for rent, utilities, and cellphone bills….” 33  Austin, 6, italics in original. 34  Austin, 6. 35  Austin, 98–99; Levinson, 236. 36  Austin, 99, italics in original. 32

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skepticism, anger; physical reactions such as blushing, cringing, yawning; or states of being such as excitement, calmness, agitation, or fear. Austin’s performatives do not remove psychological processes from the process of meaning making as Austin requires that, especially in locutionary and perlocutionary acts, a particular intention be expressed by the speaker, recognized and understood by the audience, and cognitively matched by both participants. However, in discussing illocutionary acts Austin writes, “But it is different from the locutionary examples, in that the act is constituted not by intention or by fact, essentially but by convention.”37 This is not to argue that intention is irrelevant to illocutionary performatives as intention is naturalized within the performative.38 Instead Austin shows that this form of the performative is not reliant on cognitive or psychological intentions. Austin’s illocutionary performatives (christening a ship, declaring a marriage, establishing a diagnosis, denying a mortgage) carry important situational conditions: An accepted conventional procedure that includes a required linguistic event, an assemblage of the required (authorized) people and circumstances, a procedure executed correctly and completely, and when the activity involves “certain thoughts or feelings” (such as a wedding) the people involved (“participating in and so invoking the procedure”) must “have those thoughts or feelings” and conduct themselves in a way consistent with those feelings. Austin claims that if one or more of the conditions are not met the performative will be “unhappy.” Unhappy is a careful term here as Austin writes that while the initial conditions (procedure conducted correctly by authorized people) are required, the secondary conditions (thoughts, feelings, intent) are not necessary for the achievement but a construction is “insincere” without them.39 Austin’s conditions are useful to an understanding of intention in performative discourse because they suggest that in some circumstances acts can be accomplished independent of and even antagonistically to the  Austin, 127.  The naturalization of intent within genre will be further developed in Chaps. 3 and 7 39  Austin, 14–15. 37 38

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intentions of those involved. Austin seems uncomfortable with such “infelicities” and their constructions and argues that such acts “would normally come under the heading of ‘extenuating circumstances’ or of ‘factors reducing or abrogating the agent’s responsibility’, and so on.”40 In these cases, the performative utterance itself and not the intention of the speaker achieves the act. Indeed, the discursive formation may have a different intent than the speaker. Raoul Moati puts it this way, for Austin, “[t]he act may be accomplished even if my intention does not accompany it precisely because it is the external circumstances and not the intentional capacities that permit the realization of the speech act.” Moati continues, “[i]n Austin, the reality of the speech act is thus not solely dependent on my intention to effect it; it requires circumstances propitious to its realization.”41 An important consequence for Moati is that Austin’s concept of intention “is inscribed in a global ensemble of circumstances greater than itself, over which it never possesses complete mastery.”42 Differentiating information-giving-and-receiving from other social uses of communication: politeness, face-saving, achieving common ground, challenging, warning, or simply filling time requires a nuanced and socially situated understanding of intention.43 Pierre Bourdieu similarly writes about performative (magical) and political intentions. These are linguistic forms that establish and denote power (power to name, insult, decree, conscript, constitute, institutionalize) that are enacted and understood in appropriate and precise social contexts that are acknowledged and supported by participants.44

 Austin, 21.  Moati, Raoul. 2014. Derrida/Searle: Deconstruction and Ordinary Language, trans. Timothy Attanucci and Maureen Chun. New York: Columbia University Press, 43. Emphasis in original. 42  Moati, 43. 43  Moati, 4. On “simply filling time” Brown and Yule (313) cite Pirsig, Robert 1976. Zen and the Art of Motorcycle Maintenance. London: Corgi Books. 44  Bourdieu, Pierre. 1991. Language & Symbolic Power, ed. John B.  Thompson, trans. Gino Raymond and Matthew Adamson. Cambridge MA: Harvard University Press, 105, 172–3. 40 41

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Intention and Reproducibility: From Interpretation to Production John Searle in his own elaboration of speech acts extended and systematized Austin’s performatives. Searle systematized five types of performatives that can take place in utterances: representatives, directives, commissives, expressives, and declarations. In his typologies Searle proposed structural characteristics that allowed Austin to differentiate personal (speaker) intent from the performative utterance: first that performative intent was a constituent part of the utterance itself and second, that this intent could occur outside of the psychological model.45 In doing so, Searle made two key contributions to later twentieth century rhetoric: he reasserted the linguistic role in discursive activity and he assembled a great deal of the equipment for what would become genre theory. Searle’s account claims that language is rule-governed and intentional behavior.46 As a consequence, language is durable, repeatable, and intentional. Therefore, meaning can be transmitted in speech from person to person and in writing from reader to audience (absent the author). Linguistic rules provide means for interpretation and conveyance not only in the immediate but also, in the case of writing, across time and contexts. For Searle, “any linguistic element written or spoken, indeed any rule-governed element in any system of representation at all must be repeatable, otherwise the rules would have no scope of application.”47 Further, Searle asserts that writing (and forms of speech such as recordings) provides a “relative permanence” and importantly, that the author’s intentions can be transferred in this relative permanence.48 “A meaningful sentence” he writes, “is just a standing possibility of the corresponding (intentional) speech act. To understand it, it is necessary to know that anyone  Searle, John R. 1969. Speech Acts. Cambridge, Cambridge University Press. See also, Searle, John. 1976. The classification of illocutionary acts. Language and Society, 5:1–24. 46  See Searle, 1969, passim. 47  Searle, John. 1977. Reiterating the differences: A reply to Derrida. Glyph, 1:198–208, 199. 48  Searle, 1977, 199, 201. 45

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who said it and meant it would be performing that speech act determined by the rules of language that give the sentence its meaning in the first place.”49 The citations above are from a reply Searle wrote to an essay Jacques Derrida published examining Austin’s speech acts. Derrida’s essay takes great interest in Austin’s concept, seeming to endorse the general trajectory of Austin’s argument and the general performative capacity of communication. Derrida is alternatively critical and supportive, initially critical that Austin “appears to consider speech acts only as acts of communication” but then intrigued, “Austin’s notions of illocution and perlocution do not designate the transference or passage of a thought-concept, but, in some way, the communication of an original moment (to be defined within a general theory of action), an operation of the production of an effect.”50 Derrida writes that if such an activity were possible it would offer an alternative to classical interpretations of communication in that the performative is not fixed in truth/false relationships, does not have a referent, does not describe, but it produces or transforms a situation. Ever provocative, Derrida suggests that Austin’s formulation “is nothing less than Nietzschean.” Austin, Derrida writes, “has shattered the concept of communication as a purely semiotic, linguistic, or symbolic concept.”51 Derrida argues that Austin does not go far enough. Rather than see Austin’s selective, and relatively rule-governed linguistic acts as illocutionary performance, Derrida offers that the distinctions Austin makes between appropriate and inappropriate situations for performative acts (the conditions that give rise to “unhappy” or “insincere” performatives) betray the model. Derrida argues that by dismissing the failure of performatives and especially the failure of perlocutionary acts (that an act may bring about unintended results), Austin missed the important contribution his work had made to linguistics. In other words, since performatives bring about events regardless of felicity conditions, any discourse has the  Searle, 1977, 202.  Derrida, Jacques. 1988. Limited Inc, ed. Gerald Graff, trans. Samuel Weber and Jeffry Mehlman. Evanston, IL: Northwestern University Press, 13. 51  Derrida, 13. 49 50

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possibility of production. “The opposition success/failure [échec] in illocution and in perlocution thus seems quite insufficient and extremely secondary [derive]” writes Derrida.52 Derrida asks, “Could a performative utterance succeed if its formulation did not repeat a ‘coded’ or iterable utterance, or in other words, if the formula I pronounce in order to open a meeting, launch a ship or a marriage were not identifiable as conforming with an iterable model, if it were not then identifiable in some way as a ‘citation?’”53 The answer to this question, he poses, hangs on our understanding of context and intention. Intention has an important role in meaning, Derrida writes, but it does not have the power to tie an utterance to an author nor does an understanding of context make an author or speaker’s intention any more present or viable. In his examination of the ensuing back-and-forth between Derrida and Searle, Moati writes that the debate hinged on each writer’s understanding of intention. Whereas for Searle, intention was durable, recognizable, and transmissible, for Derrida intention remains important but not in the same way. Moati writes that while both Searle and Derrida remain “attached to the concept of intentionality,” “[i]ntention is connected, for Derrida, to the circumstances of enunciation (to presence), whereas for Searle, it is to the content of the proposition, which is by no means dependent on presence.”54 Derrida’s understanding of intention is formed by his larger understanding of language and his deconstructive project. For Derrida, language exists outside of thought and psychology as an independent system that humans acquire, use, revise, and pass on to other generations. Each discursive use emerges from and is a product of a specific and transient context that can never be fully repeated or reproduced. Language, in subsequent iterations, occurs in new and different situations and, as a result, any originary intention and meaning cannot be fully reproducible. Intention is tied less and less to the origination of discourse, for with each iteration that intention is diluted in a heterogeneity of possibility. As Moati writes, “the written text empties out the intentionality of the  Derrida, 15.  Derrida, 18. 54  Moati, 88, 95. 52 53

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original thought and the intended meaning that is the source of its production: its textuality is shown to be ruled not by will [vouloir], but by iteration.”55 Maoti continues, “[w]riting bears upon the workings of language such that intentional speech derives from textuality, not the inverse” and as a consequence, the intended meaning of a statement “is revealed as forever incapable of being stabilized in the moment of communication.”56 In each iteration, the act of reading/writing, speaking/hearing activates new meaning and new intention.

Intention as an Ethical Project Derrida’s project has been critiqued as too extreme or simply inaccurate. People communicate every day and our ability to read texts and exchange meaning across generations is a fundamental staple of Western culture. My own act of (re)iterating a linguistic trajectory from Austin to Derrida would seem to deny Derrida’s hypothesis. At the same time, reading Austin in 2022 necessarily produces a different meaning than in 1962, 1972, or 1982. Reading Limited Inc influences any subsequent (re)reading of How to do things with Words. Context and situation do influence iterability, perhaps not to the extreme that Derrida posits, but once a text has left the safe confines of a particular enunciative group, meaning does not seem to be as situationally stable as Searle would prefer. How is it that people can read a scientific directive about wearing masks during a pandemic and enact radically different responses? Why will people accept modern incursions into all aspects of daily life but reject specific and singular impositions? How is it that we can suggest that certain works of art, dramatic texts, or music continue to speak to us centuries apart from their origin? Do we suppose that viewers of Hamlet see in the play the same characters, the same geopolitical struggles, and the same concepts of family and friendship as its original audience? Is the value, contention, and relevance of art, text, and writing found in the multiple reiterations that occur by unique audiences in their own histories and contexts? To  Moati, 35.  Moati, 38.

55 56

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what extent are decisions to stage Hamlet in 2022 informed by intention and to what extent should these intentions be disclosed to audiences and integrated within the reception and criticism of a staging? A simple answer is to claim that people who refused to get vaccinated during the COVID-19 pandemic were just wrong, disloyal, or misled. Yet, inscribing a meaning and intent to a text/act and enforcing strict adherence thereto across all deployments, contexts, and situations seems to presume and require a certain ideological tyranny and interpretive force. Whereas Austin and Searle claimed that misinterpreted intentions result in a lack of communication, for Derrida, a speech act is never a failure as it will still produce an event. Derrida seems more willing to allow an event ontological legitimacy (as an event) but he is keenly interested in how such events become instantiated. Here, Derrida’s deconstruction can be seen as an ethical project. The connection between an event and the enunciator’s intent is not chance but guided by a set of rules communities build to facilitate meaning production (logocentrism). For Derrida, the focus of inquiry is on the establishment of rules, on determining how meaning resulted (or was refused) within specific groups, at specific times, for very real reasons, and with actual consequences. For Derrida, inheriting (or requiring) presumed truths across generations is both less useful and ethically perplexing. Instead, he proposes methods for recognizing the intellectual systems that produced and valorized those truths, “the system of speech, consciousness, meaning, presence, truth, etc.,” that produce events. Intention, viewed as an authorial/speaker characteristic, is not irrelevant here but perhaps misplaced and misconceived. Moati writes, “the point is to accept the mixing of context through which an utterance continues to mean to say independently of and beyond its present signification.” Further Moati explains, “there exists a multiplicity of intentions contemporaneous with that to which the speaker submits, in the present moment, the signs that he mobilizes.”57 For Derrida, intent is bound up in context, situation, and in the circumstances of linguistic performance. Each time I use (iterate) language, I carry with it (trace) all of the

57

 Moati, 55.

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intentions (known and unknown to me) associated with that language. This heterogeneity must be acknowledged and accounted for in each iteration. Derrida writes that intent is a “determining center [foyer] of context.”58 But like intent, context is also bound to the specificity of the utterance. Derrida writes: By no means do I draw the conclusion that there is no relative specificity of effects of consciousness, or of effects of speech (as opposed to writing in the traditional sense), that there is no performative effect, no effect of ordinary language, no effect of presence or of discursive event (speech act). It is simply that those effects do not exclude what it generally opposed to them, term by term; on the contrary, they presuppose it, in an asymmetrical way, as the general space of their possibility.59

What Derrida is proposing here are examinations of loosely tethered aggregations that situationally produce events. These aggregations deploy intentionality even if they are not (originally) formed by it. Derrida’s reading of Austin makes Searle’s speech acts (and what will later become genres) both unlikely, because specific intentions are not durably constitutive or iterable across utterances, and not very useful because genre obscures the set of rules by which it operates. Unlike Brown and Yule’s analytic focus that sees meaning in individual discursive signs and the relationships between signs and objects (syntax, semantics) or Levinson’s pragmatics, which locates meaning in the interpretation between text and audience, Derrida seeks to examine how and why a text accomplishes action. This question does not rule out prior forms of analysis but it does not attribute those forms with innate meaning apart from what the form situationally accomplishes. Intention is important here in three ways: first in the intentions that are enacted by texts; second in the intentions that motivated that specific text’s production; and third in the relationship between these two forms of intention.

 Derrida, 18.  Derrida, 19.

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For example, in his essay “Positive Discourse Analysis” J.R.  Martin analyzes the intentions enacted by a text by former Australian Prime Minister John Howard. In the text, Howard refuses to offer an official (national) apology for historical policies that separated Indigenous Torres Strait Islander children from their families.60 In the process of his analysis, Martin contrasts discursive features from Howard’s text with a newspaper editorial condemning Howard’s position. We will return to Martin’s larger project below but what is relevant here is his finding that both texts use similar discursive features. As Martin notes, the features themselves (in this case nominalizations) carry little meaning or ideological positioning. “This [the editorial] text is just as nominalized as Howard’s,” explains Martin, “with the same kinds of repercussions for agency, arguability, and information flow.”61 Martin continues, “Concrete discourse is just as ideologically positioned as nominalized discourse; neither discourse is intrinsically more disordered than the other.”62 As Martin shows, there is no aggregation between particular discursive features and so-called good intentions or bad intentions. Concluding his analysis, he cautions against seeing in discourse “the X-Files’ fallacy” a belief that “unpacking grammatical metaphors will expose what is really going on” in discourses we disagree with.63 Rather than critique ideological discourse as distorted, Martin shows how an analysis can acknowledge and investigate a writer’s intention, what Martin calls the “interested” truths that are achieved by the nominalizations. As an example of marking the intentions that motivate production we can note that Derrida’s reply to Searle does not deal with semantic argument (truth/falsity, right/wrong) so much as the motivations on display in Searle’s argument. The reply aggregates the textual study of intention and an author’s own intentions for a specific critique (or research project). Derrida asks why Searle felt motivated to sign his reply, to authorize it (if meaning and intent are consciously reproduced between reader and writer across contexts, authors would have no reason to authorize/  Martin, James R. 2004. “Positive Discourse Analysis: Solidarity and Change.” Revista Canaria de Estudios Ingleses, vol. 49, pp. 179–200. Subsequent citations refer to manuscript page number. 61  Martin, 4. 62  Martin, 4–5. 63  Martin, 5. 60

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validate their work). Derrida asks why Searle characterizes Derrida’s reading of Austin as a “confrontation” and later he writes that his analysis does not pertain to “constituted elements of the ensemble” but rather to “the essentially interminable character of such an analysis.”64 What would provoke this response, at this time, with these particular accusations? What are the knowledge-rules that Derrida is presumed to have violated and why are these rules particularly salient and sacred? Derrida seems to be claiming that if we are going to study language as intentional behavior, we should be more upfront about our own intentions when researching, writing, and engaging with others. As an example of our third use, the aggregation of textual study and scholarly intent, in his examination (and demonstration) of science writing pedagogy, Martin discusses a report about the Australian literacy curriculum written by American and British educators. Martin argues that the authors co-opt post-structuralist critique of systems to advocate for their own biases in literacy education. As Martin explains, the report argued that Australian literacy education denied students’ individuality because students were taught hegemonic writing products (genres). Instead, the authors proposed that students be free to express their own individuality in their writing and not be held to structural requirements. Martin argues that the ideological outcome here is directly opposed to the supposed post-structuralism that informed the critique: in the free writing proposed by the report not only do students not learn the technical specifics that create linguistic currency within hierarchical systems but they also miss the context and opportunity to examine the machinery that gives rise to privileged discourses.65 Echoing M.A.K.  Halliday’s observation that “only those who have had the privilege of being modern can afford the luxury of being postmodern,” Martin writes, “these students need to learn to deconstruct both technical and anti-technical discourses, and abstract and anti-rational ones to succeed in tertiary

 Derrida, 13, 39.  A machinery that Martin demonstrates throughout the chapter.

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education in the late twentieth century.”66,67 Addressing the intent of the report’s authors, Martin writes, “[w]hen anti-rationality is co-opted to shore up progressive education in this way, the results are potentially damaging.”68

What Is the Intent of Critique? In both his examination of science writing pedagogy and his proposal for a positive discourse analysis (PDA), Martin raises an important but not often considered issue for textual criticism: What is the intent of critique? What do analysts hope to achieve when engaging with discourse? In his PDA proposal, Martin describes what he calls the “two faces” of critical discourse analysis. The better-developed “face,” he writes, is the deconstructive, “concerned with exposing language and attendant semiosis in the service of power.”69 This retrospective critical approach has remained influential and has made important contributions to our understanding of the ways power is embedded within textual practices. It examines what Chouliaraki and Fairclough describe as the way discourse both constitutes and reflects societal practices and it fulfills their (and others’) contention that the social is “built into the grammatical tissue of language.”70 Here, close analysis can show (deconstruct) hierarchy, power, injustice, and inequality operating within and reinforced by textual practices. Martin’s second, “complementary” face, he writes, “is oriented not so much to deconstruction as to constructive social action.”71 He writes that, “deconstructive and constructive activity are both required” in 66  Halliday, M.A.K. 1993. “Language in a Changing World Occasional Papers 13. In On Language and Linguistics: The Collected Works of M.A.K. Halliday Vol 36. (ed. J. Weber). Applied Linguistics Association of Australia. p. 218. 67  Halliday & Martin, p. 266. Martin’s point here is that the robust understanding discourse analysis can provide into and across social structures will never be learned by students if they are merely taught to passively inherit or uncritically perform the written language that is key to their education. 68  Halliday & Martin, p. 265. 69  Martin, 2. 70  Chouliaraki, Lilie & Norman Fairclough. 1999. Discourse in Late Modernity: Rethinking Critical Discourse Analysis. Edinburgh: Edinburgh University Press, p.1; p. 140. 71  Martin, 5.

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textual research; yet, for the most part, retrospective critique has dominated textual analysis.72 Not only has critique been the dominant orientation of textual study, Martin explains, but, researchers have continually emphasized critiques of discourses that disempower and oppress. Martin writes, What concerns me most in arguing for constructive research is to undo an apparently pathological disjunction in 20th century social sciences and humanities research which systematically elides the study of social processes which make the world a better place in favour of critiques of processes that disempower and oppress. So instead of heartening accounts of progress we get discouraging accounts of oppression.73

The consequence of this orientation has been an inability to see how textual strategies could be used productively to intentionally design better futures. As Martin writes, “this means that when we come to design better futures we simply don’t have enough information to move forward.”74 As an alternative, he proposes his PDA, a study that would teach us how change happens and how people use discourses to design more productive futures.75 Martin continues, The lack of positive discourse analysis (PDA) cripples our understanding of how change happens, for the better, across a range of sites—how feminists re-make gender relations in our world, how Indigenous people overcome their colonial heritage, how migrants renovate their new environs and so on. And this hampers design, and perhaps even discourages it since analysts would rather tell us how struggle was undone than how freedoms were won.76

Martin writes that such an approach requires analysts to display their values. It also requires that a report effectively analyze intention and have  Martin, 6 emphasis in original.  Martin, 7. 74  Martin, 7. 75  Martin, 8. 76  Martin, 7–8. 72 73

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and declare its own intent. It would also require alignment between the critique and the intent of the researcher/analyst, a relationship that has not always been foregrounded or appropriately considered in humanities scholarship. Martin’s proposal has deep roots in modern textual studies. Halliday, for example, wrote of applied linguistics as an equally active and interventional project as a descriptive one. He argued that description leads to understanding that can then be applied to intentional change. “Meanwhile, we have to enable people to control the discourses that now surround them,” Halliday writes, “and the energies of applied linguists are very much taken up with language education work of this kind.”77 Like Martin, Halliday argues, if knowledge is construed in language, then those who want to open up access to such knowledge not only must themselves understand, but must also enable the learners to understand, how it is that language does its work—how the grammar of every language provides the power for interpreting and acting on the world.78

Halliday characterizes this work as “design” and he asks, during times of historical change, when we see a potential new confluence between the material and semiotic, “do we intervene? Do we try to import some design into these essentially evolutionary processes?”79 It is a tempting proposition. Yet, “[t]he problem is,” Halliday writes, “we do not know how to do it….”80 To learn how, he proposes, we need to study the efforts people have made to intentionally change their language, “to design language” Halliday offers, and he cites as examples the origins of scientific discourse and the linguistic work of modern feminisms.81 Here, intentional changes in both text and speech generated new semiotic systems, new systems of hierarchy and power, and new ways to engineer social change.  Halliday, 228.  Halliday, 229. 79  Halliday, 221. 80  Halliday, 221. 81  Halliday, 225. 77 78

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Intention as Discursive Practice Sara Cobb developed a similar repositioning of intention, discourse, and activity within critical discourse analysis (CDA) and in recent years other reports have renewed calls for a greater orientation toward productive social change within discourse studies and more proactive accounts of how discourse can be applied to positive social action.82 Writing in the wake of the Rodney King trial, Cobb argues that CDA at the time was unable to adequately explain how texts enacted meaning because the field inherited an individualistic and overtly conventional (generic) understanding of intention. She argues that the individualistic orientation wrongly overemphasizes an individualistic, cognitive, and isolated subject who has either buried intention or is unaware of intent (unintended consequences). In both cases, Cobb writes, the role of the analyst has been to use discursive clues to resurface individual intentions in the form of either “false consciousness” or “resistance.”83 Writing about the trial, Cobb notes that critics focused on the individual intentions of the judge and the intentions of the all-white jury, noting “What is at issue in this genre of critical analysis is the accurate depicting of inner reasons for people’s actions: the ‘discovery’ of their true intentions.”84 Following this orientation toward individual intentions in CDA, Cobb writes that explanations position people in two extremes, “either persons are duped by the powerful or they are resisting oppression.” She argues, “both explanations are tautological—neither can be proved or disproved as long as analysts assume that persons may not know or may falsify their intentions.”85 Further complicating this analysis, Cobb writes, is that since intention is “read off action” there is no empirical justification for what a critic claims. Such an approach would then re-impose the very hierarchical power structures onto subjects that CDA’s defenders claim they are attempting to dispel.  Cobb, Sarah. 1994. “A Critique of Critical Discourse Analysis: Deconstructing and Reconstructing the Role of Intention.” Communication Theory 4(2): 132–152. 83  Cobb, 134. 84  Cobb, 132. 85  Cobb, 134. 82

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Cobb argues that other CDA practitioners were less motivated to viewing the individual as the nexus of agency and instead focused on conventions or genres of discourse. These researchers saw human action as constructed by community norms and social conventions. Here genre stands out as a primary device for organizing, deploying, and examining discourse and social action. However, as Cobb writes (and as will be developed further in Chap. 3), a focus on genre avoids the problematics associated with trying to understand how individual speakers negotiate context and how a speaker (or writer) physically accomplishes an intention when faced with social, economic, power, and other constraints. But it accomplishes this by avoiding a discussion of intention altogether. In Cobb’s words, “it does so by obliterating a focus on intention.”86 Cobb argues that in avoiding intention, conventionalist critique becomes equally tautological: “In describing ‘reproduction,’ dominant discourses are described as maintaining their dominance by ‘eclipsing,’ ‘marginalizing,’ ‘subverting,’ ‘coopting,’ ‘silencing,’ ‘incorporating,’ and ‘transforming’ discourses that challenge their authority.”87 “Agency is located in the discourse itself ” Cobb argues, “subjectivity is displaced, objectified in the ‘signs’ (speech conventions) that render persons incapable of altering the conditions of their own oppression.”88 Echoing Halliday and anticipating Martin, Cobb argues that a convention-focused CDA remains oriented toward retrospective critique and a circular recounting of domination. She writes, “It [CDA] can not account for the ways persons in conversation, at local levels, can transform or alter the discourses that contribute to their own domination and marginalization.”89 Cobb makes an important distinction between intention and agency. Agency can be studied linguistically through features like verb transitivity, presupposition, syntax, and nominalization. However, intention requires purposeful action, what Cobb calls “agency and directionality.”90 For this reason, the study of intention requires more than grammar or  Cobb, 135.  Cobb, 135. 88  Cobb, 135. 89  Cobb, 136. 90  Cobb, 148. 86 87

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discourse but necessitates a larger contextual and reflexive assessment. At the same time, intention is not narrowly cognitive or “of the mind” as it requires discursive formation. As Anscombe writes, an inquiry into intention must first study “what a man actually does” and connect this action to the discourses that identify “why” such action took place.91 Cobb’s proposed alternative understanding of the relationship between intention and discourse aligns with Derrida’s production of events and her proposed form of analysis echoes Halliday’s proposal to study actual uses of intention and actual ways people use language to change language and social position. Following Anscombe, Cobb situates intention as not a cognitive or mental process, but as a discursive practice—“a language game in which actors use ‘because of ’ or ‘in order to’ to account for actions.”92 Intention, unlike desire, requires discourse, it must be discursively formed and physically enacted. Methodologically, “because of or in order to” formulations provide a logical connection between actors and actions in narrative structures.93 Ordering such events into “causal sequences” creates narrative and temporal elements and, as Burke demonstrated in his dramatistic model, researchers can position constituent parts in ways (ratios) that demonstrate reasons for action.94 Following Derrida, “because of or in order to” statements are neither transcendent nor universally meaningful. Nor are they uniquely cognitive or individually of the mind. They are situationally graphed onto discourse, activity, and context to produce intention. Here, intention is not a characteristic of the mind but a position borrowed through discourse. Like Halliday, Cobb proposes investigating intention at specific sites where intention matters, in sites like courtrooms, policy forums, and news accounts. In these spaces, intention is positioned and contested and its attribution has very real consequence. Circling back to the Rodney King trial, Cobb writes that more effective (and productive) questions  Anscombe, 9.  Cobb, 138. See discussion on Anscombe Intention in Chap. 3. 93  Cobb, 139. 94  See Chap. 6 for a working model of how Burke’s Dramatism can be used to investigate intention within large social institutions. 91 92

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would ask how and where was intent located; how was intent assigned value (good intent, bad intent); how was intent and activity productively overlaid; and how was intent used to construct the identities of those participating in the trial (police, Rodney King). Cobb would have investigations examine “what people actually do” when intention is at stake, how people productively claim intention, and how intention is used to justify action.

What Goes Around Comes Around Twenty-four years after Cobb’s essay, sixteen years after Martin’s proposal for a positive discourse analysis, and twenty-eight years after Halliday argued for studies tracing the efforts people have made to intentionally change their language and their social status, Mariaelena Bartesaghi and Kate Pantelides offered their own take on action in critical discourse analysis, writing, “discourse analysis with a critical thrust should be more than an examination of language’s ‘political slant.’ Rather, it must move us to do something that matters.”95 Bartesaghi and Pantelides recognize the historical situatedness of their claim and, citing a similar directive written in 1979 by Fowler and Kress, recognize that efforts to produce more practical and enactive discourse studies have sporadically attempted to reform CDA scholarship. Bartesaghi and Pantelides review what are familiar criticisms of CDA and pay special attention to the difficult position intention holds for discourse studies. For example, they argue that the linguistic models used throughout CDA research tend to be circular and tautological rather than empirical; that CDA’s own technical vocabulary and its structural orientation toward language often re-impose the same hierarchies and agentless actions its proponents criticize; and that its analysis often reinforces the very same oppression that it seeks to reveal

 Bartesaghi, Mariaelena & Pantelides, Kate. 2018. “Why Critique Should Not Run Out of Steam: A Proposal for the Critical Study of Discourse.” Review of Communication 18(3): 158–77. p. 159. 95

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either by speaking for oppressed people or by structurally defining specific groups as marginal or oppressed.96 As points of intervention into a reconstructed Critical Discourse Studies (CDS), Bartesaghi and Pantelides recommend a greater interest in and use of reflexivity, multimodality, and interdisciplinarity for discourse studies. Their proposal is well taken and could lead to impressive changes within the field. Reflexivity would provide space for researchers to integrate qualitative fieldwork, ethnography, personal reflection, and it could help to reorient technical discourses into language more widely accessible. Reflexivity would also provide space for scholars to reflect on their own project and as Martin addressed above could ask scholars to identify and explain their intentions for embarking on a particular project and their goals for what that project might achieve. Multimodality reorients the focus of analysis away from a narrow field of grammar and toward a larger interplay of materiality, physicality, vision, hearing, and sensation. This notion of multimodality is reminiscent of Lyon’s physical recognition of intention, the smile, eyes, voice, and sweat she writes that are associated with performance. Lastly, greater interdisciplinary within discourse studies would open the field to more diverse perspectives, cultures, and expertise. With inclusion of a more diverse scholarship and experience, discourse studies could have greater applicability and relevance for wider audiences. Bartesaghi and Pantelides are part of a renewed conversation about how to make textual studies more relevant, applied, and productively useful for problem-solving. Indeed, Bartesaghi and Pantelides’ proposed interventions, reflexivity, multimodality, and interdisciplinary, are found throughout the chapters that follow. Similarly, my goal throughout this book is, following Martin, to balance deconstructive and constructive work. At the same time, despite these efforts, we still lack good proposals  Bartesaghi & Pantelides, pp. 162–164. See also, Tracy, Karen, Susana Martinez-Guillem, Jessica S. Robles, & Kimberly E. Casteline. 2011. “Critical Discourse Analysis and (U.S.) Communication Scholarship Recovering Old Connections, Envisioning New Ones.” Annals of the International Communication Association, 35(1): 241–266. Tracy et al. review similar critiques of CDA citing arguments that claim CDA pays insufficient attention to speech, it is not methodologically rigorous or linguistically accurate, its academic jargon is inconsistent with its emancipatory principles, it pays too little attention to material constraints and actual change, and it assumes a Western world view as normative (pp. 260–266). 96

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and strong models for how humanities-based textual scholarship can be productive. This is the core problem that the chapters that follow attempt to articulate and address. My field of action, given my own disciplinary training, is textual studies and my suggestion is that we start by reconsidering a concept that was sidelined when “critique as scholarship” became instantiated as sufficient—that concept is intention. As the review above shows, when reconsidering intention several things happen in textual studies and these are themes throughout the chapters that follow: We question genre and its role in suppressing intention, we reconsider how we teach writing, we begin to talk about production and the ethics of conscious design, we form our own discourses of production, we investigate our own motivations when we act, we try integrating critique with production/action, and we engage in reflection as a way of learning. As Derrida argued, there is nothing transcendently available in the utterance itself that encodes/decodes an original and permanent intent. Intents are situationally graphed onto language to produce an effect. Derrida endorses the performative but as a situationally restricted act. The point here is not to conclude that understanding is impossible or that language does not work/have effect. Derrida notes that these things occur “every day.”97 But they do not occur by transferring pre-conceived meaning or decoding meaning; they occur through aggregations of situation, text, history, writing, consciousness, space, demographics, what we generally (imprecisely) refer to as “context.” Intention is embedded within these aggregations and these aggregations are deployed as performances or actions. As Martin argued about teaching writing, Disaggregating (deconstructing) performance tells us more about intention and meaning than simply reading and relaying (inheriting) the semantic content the performative provides. This brings us then to the first term in my subtitle: Curation and Curating. I am using the term as a substitute for genre and as a way to articulate a situational, constitutive act that produces the results of a discourse at a moment. Unlike genre, which naturalizes intent and presumes recognition, durability, and regularity, curation temporarily deploys 97

 Derrida, 20.

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intention in a circumstance of use. To curate a discourse is to aggregate intents, discourses, and situations (among other things) to produce (an event, a result, a consequence). Curation also implies and accounts for agency. Curation does not negate genre, genres may continue to persist and remain useful for some activities, but the end of genre recognizes genres as curations and here we are interested in their aggregations, their rules of deployment, and what they make (im)possible. The suggestion here is that at the end of genre we have curation.

Experiments: Interpretation and Production The end of genre also enables experimentation. Returning to Lyon’s (re) introduction of intention to rhetorical theory, I would like to pull forward an important consideration she makes while articulating the generative capacity of intention for rhetorical studies. Lyon writes that she is “puzzled by the interpretive turn within rhetoric.”98 While acknowledging that interpretation necessarily has a role within rhetorical studies, she wonders why, from her perspective, the field elevated interpretation at the apparent expense of rhetoric’s more familiar expertise, production. Lyon puts it this way, “I wonder if interpretation’s place in public discourse and democratic practices cannot be theorized in other disciplines while rhetoricians focus on rhetoric’s familiar areas of expertise, such as the production of texts and their relationship to political action.”99 Lyon concludes this argument with a claim that I, too, endorse and have attempted to enact in my own engagement with intention in this book. She writes, “I am ambivalent about characterizing rhetoric—as a theory, let alone a practice—as predominantly interpretive.”100 What does it mean to engage intention from a perspective that is not predominantly interpretive? This book is curated as a series of experiments, in Dewey’s sense, with intention. It is also reflected in Burke’s

 Lyon, 12.  Lyon12 100  Lyon13. 98 99

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formation of intention from an interpretative to a productive term.101 In his book Essays in Experimental Logic, John Dewey develops a theory of practical knowledge, an understanding developed through active engagement and experience. “We do not know the origin and nature and the cure of malaria till we can both produce and eliminate malaria,” Dewey writes. “The value of either the production or the removal depends upon the character of malaria in relation to other things.”102 And, “[t]heir usefulness when made is whatever, from infinity to zero, experience may subsequently determine it to be.”103 For Dewey, knowledge is formed through engagement and experience. “Practical application” defined by Dewey as “experiment” is a condition of knowledge, or in his words, “indispensable to the institution of knowledge or truth.”104 As Paul Rabinow, whose encouragement brought me back to Dewey’s work, writes about his own project, knowledge “has seemed to be best done by doing it, that is to say, by laying out examples and reflections on those examples.” Doubling on Rabinow’s words, “my inclination is more to show than to tell.”105

Intention as a Speculative Instrument The chapters that follow are my own attempts at experimenting with intention and, following Rabinow, at laying out examples and offering reflections on those examples. What I mean here is that each chapter uses intention as a “speculative instrument” to use equipment introduced by I.A. Richards.106 As Richards posed, I am attempting to use intention as an instrument “to increase familiarity with situations in which we are trying to see what is being said and trying to separate it from what is not being said, situations above all in which we would, if we could, investigate  See Burke, Kenneth. 1969. A Rhetoric of Motives, Berkeley: University of California Press, 154–158 and discussion in Chap. 5. 102  Dewey, 212–213. 103  Dewey, 212–213. 104  Dewey, 281. 105  Paul Rabinow. 2008. Marking Time: On the Anthropology of the Contemporary. Princeton NJ: Princeton University Press, 1. 106  I. A. Richards. 1955. Speculative Instruments. New York: Harcourt, Brace, & World. 101

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our intellective instruments themselves, the tools with which we work in all investigation.”107 In building on earlier work, I am attempting to move beyond a grand scholarship of instantiation and critique and toward something more minimalist, incremental, and productive.108 I will address this again in subsequent chapters that consider the function, intent, and influence of an integrated humanities scholarship. Instead, while acknowledging prior important and comprehensive contributions about intention, I embark here to instrumentalize these contributions and not reproduce them. My aim here is incremental production, to experimentally test what intention can tell us about problem solving and reciprocally what solving problems can tell us about intention. The chapters attempt to demonstrate that intention can function as a generative instrument for understanding and enacting instrumental and professional discourse in partnership with other fields and areas of expertise. But I do not suggest that the outcomes of the experiments narrated here were predetermined or even complementary. As these things go, some are more successful than others. My goal here has been productive, to use intention as an instrument to increase familiarity with events that alternatively seemed to occur in unexpected tangents, counterintuitive duplicity, fluent exigency, or a stubbornly mired stasis. Each chapter  Richards, x.  My approach has been strongly influenced by Paul Rabinow’s articulation of an anthropology of the contemporary which he refers to a moving study of modernity that recognizes its (own) temporality. In short, “the modern” is not examined as an epoch or hierarchy but as a configuration of old and new. Rabinow cites the example of the human genome—despite the fact that the human genome has been sequenced and humans can be understood at new cellular and genetic levels, older notions of race continue to persist. An anthropology of the contemporary is also concerned with the tensions within social reproduction, sociological examination, and emergence, adaptation, and other forms of accommodation. These studies are not conducted through traditional ethnography or with the usual focus on human behaviors but instead attempt to understand the conflation of available knowledge, human action, and the power relations that validate, complicate, and disseminate the claims produced through these relations. Rabinow writes that the scope here is minimal and narrow and oriented to practice, or experimentation, rather than grand theorizing. Articulating his method, one element stands out for me as particularly relevant for my own approach in this book. Tracing Dewey’s approach to inquiry, Rabinow writes, “Since the problem lies in the situation and the situation is conditioned by various factors, it is only through discovering and giving form to elements that are already present that the inquiry can proceed. Hence the process involves staying in the midst of the things of the world and transforming them in specific ways so as to given them the kind of determinative form that can be known.” Rabinow, 2008, 9; see also, 1–5, and Paul Rabinow, 2003. Anthropos Today: Reflections on Modern Equipment. Princeton, NJ, Princeton University Press. 107 108

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makes its own incremental addition to this project but I do not hold out any grand scheme, meta-narrative, or new “ism” apart from hoping that readers will undertake their own experiments either with intention or with other useful rhetorical equipment. Without being prescriptive, I hope that the results of such experiments will result in instrumental and professional discourses that better remediate the human and the scientific.109

Experimentation The rationale for each experiment was outlined in Chap. 1, which framed the book’s project through a personal encounter with physiological, personal, and professional intentions and the ways these intentions intersected and influenced significant and meaningful decisions. This chapter and the others that follow are designed as experiments in recognizing, understanding, and enacting intention. Following Rabinow, my objective is to trace encounters with intention as I perceived the concept informing my own and others’ discursive practices. Several experiments are written from an unapologetically personal perspective. This is because, as Anscombe and Woodword write, intentions are necessarily personal. But at the same time, the narratives here suggest that intentions can inform purposes, goals, and actions in ways agents do not fully realize or understand. The spaces encountered here are chosen and restricted by opportunity, expertise, and out of respect for the substantial technical and field knowledge that constitutes professional work. Unlike Woodward, I deliberately did not include law and legal rhetoric because the constitutive role of intention in legal proceedings, especially in criminal law, is obvious and

109  I intentionally borrow the term remediate here to evoke the aggregation of existing concepts into repurposed actions and to signal a hope-for improvement in productive relations going forward. See Rabinow, 2008, 127–128; on remediation and new media, see Bolter, Jay David and Richard Grusin. 1999. Remediation: Understanding New Media, Cambridge MA: MIT Press (cited by Rabinow, 2008, 128).

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well established.110 I also did not include the clergy or religious discourses, which, I think, necessitate their own separate project. This does not imply superficial or risk-free practical encounters. My experiments with nanotechnology (Chap. 3) were developed through highly productive and completely dysfunctional work with engineers and scientists working at the forefront of what, at the time, appeared to be a new (applied) scientific discipline. These encounters were structured by grant proposals, undergraduate courses, a requirement for “ethical” or “societal dynamics” work imposed by external funding agents, and my own interest and research in tracing the emergence of a new field. The work described in Chaps. 4 and 6 is informed by education in paramedicine and over a decade of practice in pre-hospital care. The work in metrics that informs Chap. 5 emerges from practical experience gained from full-time employment as a healthcare quality data analyst and subsequent consulting and teaching in the field. The experimental knowledge of intention formed through these experiences was admittedly retroactive and reflective as I considered whether and how intention informed the work that occurred in these spaces.

An Intentional Humanities A considerable narrative common to this project and to those precursors that have informed my understanding of intention and what it means to do scholarship is the restoration of a form of humanities inquiry that is integrated with and essential to scientific practice. This is a humanities that is represented in Edmund Pellegrino’s conceptualization of medicine as “the most humane of sciences, the most scientific of the humanities.”111 Or in William Osler’s remark that “the so-called Humanists have not

 In writing this I recognize the irony that the professional field perhaps most astutely and keenly occupied with intention is law, which can be interpreted as applied rhetoric. 111  Fins, Joseph. 2015. Edmund D.  Pellegrino, MD 1920–2013. Transactions of the American Clinical and Climatological Association: 126. (Cited by Morgan, Matt. 2019. When bullet points miss the heart. British Medical Journal 366: 15500). 110

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enough Science, and Science sadly lacks the Humanities.”112 What is envisioned here is a more practical, engaged, and applied humanities, with tools and equipment that need to be both recovered and redeployed. I’m not suggesting that an intentional humanities should be universally adopted or that what amounts to complex and difficult interdisciplinary work is appropriate for everyone. But for those trained in traditional humanities disciplines who had envisioned greater applicability, collaboration, and utility of their training, rhetoricians and writers who had hoped that the humanities could help to address complex human problems, this project offers some initial tools. While I recognize the fallacy of imposing current articulations on Osler’s and Pellegrino’s historical context, I also recognize the potential for a type of humanities scholarship that is better aligned with and relevant to the projects of contemporary science. Here I think of projects like nanotechnology, synthetic biology, genetic manipulation, and even new forms of disease management like immunotherapy, personalized medicine, population health, and disease prevention. The irony here, as I show in Chap. 4, is that in many cases, practical scientists are the experts who are calling for this more engaged humanities scholarship.113 My speculative claim is that a deliberative and productive discourse of intention within the humanities is necessary for establishing meaningful collaborations with the pure and the applied sciences and with the professions that emerge from these disciplines. Here, I agree with Halliday who argues that while we would like to know how to positively intervene when we see change happening, “we do not know how to do it….”114 Following his advice, I studied and participated in efforts scientists, engineers, physicians, process-improvement specialists, and managers have made to  Bliss, Michael. 1999. William Osler: A Life in Medicine. Toronto: University of Toronto Press, 461. 113  See for example Howley, Lisa, Elizabeth Gaufberg, and Brandy King. 2020. The Fundamental Role of the Arts and Humanities in Medical Education. Association of American Medical Colleges. From the report’s executive summary, “The AAMC believes the arts and humanities can play a unique and unrealized role in preparing and equipping physicians for 21st-century challenges.” The report’s first recommendation states, “Assert that the practice of medicine is an art as well as a science, requiring a grounding in humanistic values, principles, and skills, including a deep understanding of the human condition” (1). Also see postscript in this book. 114  Halliday, 221. 112

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intentionally change their workplaces, disciplines, clinical practices, and discourses in efforts to make larger changes in the world. Here I diverge from Woodward who sees no role for intention in science, “the language of intention is not properly within the lexicons of mathematics or genetics at all” he writes.115 And, it is here where our use of intention differs as well. Intention rightly offers Woodward a critical tool for understanding other human beings, to recognize another’s values, that by understanding a person’s motives we can better understand another’s character and reflexively our own. “Intent may be a state we assign to others” her writes, “But attributions originate in us.”116 However, as noted above, my project is marked by a prejudice toward activity, engagement, and in finding a more productive role for the humanities in crucial yet sticky problems. Unlike Woodward, this book will argue that intention is foundational to science, engineering, and to professional work. It will also argue that without a discourse of intention, the humanities have little, if any, common ground with STEM disciplines that have largely taken sole responsibility for practical and useful problem solving in the twenty-first century. Carl Herndl has described a similar project as an “engaged rhetoric of science.” 117 “This is not a simple, straightforward, or unproblematic task,” Herndl writes, but he also argues that “this is a pressing need and a promising opportunity.”118 The task of an engaged RSTEM (rhetoric of science, technology, engineering, and medicine) is an extension of a larger project in rhetoric and writing studies to further community and civic engagement. Working from Latour’s We Have Never Been Modern, Herndl articulates a focus for RSTEM that is not simply critique, “to use  Woodward, 5.  Woodward, 133–134. 117  Herndl. Carl G. 2017. Introduction to the symposium on engaged rhetoric of science, technology, engineering and medicine.” Poroi 12, https://ir.uiowa.edu/cgi/viewcontent.cgi?article=1259& context=poroi. See also: Eble, Michelle and Lynee Lewis Gaillet. 2004. Educating ‘community intellectuals’: Rhetoric moral philosophy and civic engagement. Technical Communication Quarterly 13(3): 341–354. See also, Hass, Angela M. and Michelle F.  Eble (eds). 2018. Key Theoretical Frameworks: Teaching Technical Communication in the Twenty-First Century. Louisville, CO: Utah State University Press. Specifically, Natasha Jones and Rebecca Walton’s chapter, “Using narratives to foster critical thinking about diversity and social justice.” Jones and Walton call for “an intentional focus on social justice, diversity, and inclusion” in technical communication pedagogy (241). 118  Herndl, 1. 115 116

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deconstruction or critical theory to dismantle the traditional notion of science,” but to work “upstream” of science on projects that matter and are relevant to people’s day-to-day lives.119 My own impulse has been complementary to this notion of working upstream, rather than the more typical retrospective, after-the-fact (“downstream”) critique and finger pointing.120 But more acutely, my goal as an engaged humanist has been to work simultaneously with science, as Rabinow puts it, to stay in the midst of things. Here, intention is a valuable tool as it forces us to ask and clarify “why” and negotiate the line answers draw between critique and practice. The point of an engaged RSTEM is not practice or engagement without self-awareness or accountability, and it is here that intention can add one of many useful contributions. As Herndl also notes, the goal here is something larger than “broader impacts,” or instrumentalist marketing, public relations, and crisis communication for scientists who would prefer to remain in the lab. The problem is not without its complexities. “We want to participate in mission-oriented science projects that often induce us to embrace the ethos and framing of science” writes Herndl, “but this often makes it difficult to maintain some critical and analytic difference and distance.” The goal here is not to supplant or replace STEM expertise but to complement and enhance problem solving by developing and contributing our own unique tools and capacities. As Herndl notes, our knowledge, skills, and different areas of emphases and expertise, appropriately deployed, are “what makes us useful.”121 This more disciplinary intention for the book brings us back to Lyon’s interest and aggregated intentions for her own project. Lyon argues that in advancing a renewed interest in intention she is pursuing a social and political project. She writes of a renewed deliberative rhetoric as a way to restore and rebuild a revitalized public sphere. By examining competing intentions within political discourses, Lyon writes 119  Herndl, 2–3. See also Latour, Bruno. 1993. We Have Never Been Modern. Cambridge, MA: Harvard University Press. On the upstream/downstream metaphor, Herndl cites Collins, Harry. and Robert Evans. 2002. The third wave of science studies: Studies of expertise and experience. Social Studies of Science 32.2: 235–295. 120  See for example, Codding, K. & Faber, B. 2019. “Scientific emergence and instantiation II: Assembling synthetic biology 2006–2015.” Journal of Business and Technical Communication 33(3): 268–291, https://doi.org/10.1177/1050651919834981 121  Herndl writes, “That different is, however, much of what makes us useful” (8).

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that she hopes to increase deliberation and thereby expand participation in public and political action.122 Lyon’s grounding of intention within her contemporary social and political discourses is salient to my own project. In his book, Bibliography and the Sociology of Texts, D.  F. McKenzie explains how scholarship is contemporary with cultural, economic, and political conditions. He argues that understanding “the reasons why texts were written and read as they were, why they were rewritten and redesigned, or allowed to die,” what he calls “the sociology of texts,” provides greater insight into the meanings those texts provide.123 Investigating the production of a text means asking what forces resulted in the aggregation of a particular topic, approach, text, production, or interpretation at a specific time? What immediate and historic conditions led an author to pursue a particular subject and what conditions enabled and guided a particular interpretation? McKenzie grounds his argument in a perceptive examination of W. K. Wimsatt Jr. and M. C. Beardsley’s essay, “The Intentional Fallacy.”124 I will return to McKenzie’s examination of the essay in Chap. 3. For now, I want to emphasize McKenzie’s larger project, that writers will interpret and report data in ways that are consistent with “the needs of their own time.”125 McKenzie’s point is that specific social conditions make subjects available, data identifiable, and conclusions possible and that bibliography can provide access to the “social motives” involved in textual production.126 In the case of Wimsatt and Beardsley, institutional conditions and the professionalization of literary criticism as a field legitimized and established a new field called English studies, hastened the decline of Classics (and Rhetoric), and supported a new perspective of textual interpretation that empowered the objective authority of the critic. McKenzie  See Lyon,12; 18–20.  McKenzie. Donald. F. 1999. Bibliography and the Sociology of Texts. Cambridge: Cambridge University Press, 13. 124  Wimsatt William K. and Monroe C. Beardsley. 1946. The intentional fallacy. Sewanee Review 54: 468–488. Revised and republished in Wamsatt, W.K. 1954. The Verbal Icon: Studies in the Meaning of Poetry, University of Kentucky Press, 3–18. 125  Wimsatt and Beardsley, 22. 126  Wimsatt and Beardsley, 29. 122 123

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argues that together, these conditions enabled a misreading that gave rise to and reinforced the suppression of intention in literary interpretation. If the expulsion of intention as a critical tool became a prerequisite for the emergence of professional literary (and art) criticism and if, as Lyon argues, the perceived lack of a pluralist, inclusive, and judicious public sphere made it possible for intention to be reinstated (if only briefly), what might be at play currently that would turn our attention again to intention as a rhetorical instrument? In a 14 September 2020 article, Joshua Yaffa, Moscow correspondent for the New Yorker, reported on the now familiar Russian disinformation campaigns and their manipulation of social media to create distrust in Western democracies. After describing these campaigns and their coordinated efforts to disrupt American’s faith in government, promote conspiracy theories, and subvert legitimate news organizations, Yaffa writes, “The challenge in making sense of disinformation operations is disentangling intent from impact.”127 As Burke’s “Pascalian principle of rhetoric” shows, corrupt and disingenuous discourses, theological and otherwise, are nothing new. Yet, over the past two decades we have witnessed a growing institutional legitimacy of disingenuous argument. Whereas linguists like George Lakoff have documented how terms like “freedom,” “death tax,” “tax relief,” and “waste” have been used to frame policy debates, more recent discursive formations have doubled down on such rhetoric.128 Lee McIntyre notes that “post-truth” was named the 2016 Oxford Dictionary word of the year, with a 2000 percent increase in the term’s use from 2015.129 He writes that the term “post-truth” does not imply that we are “past” truth, but that “truth has been eclipsed—that it is irrelevant.”130 McIntyre enumerates world-changing events—smoking is not harmful, Iraq had weapons of mass destruction, Brexit would economically benefit the UK, antiretroviral AIDS drugs are a geopolitical plot, and climate change is  Yaffa. Joshua. 2020. Believe it or not. New Yorker, (Nov 14), 27; emphasis added.  See for example, Lakoff, George. 2014. The All New Don’t Think of an Elephant: Know Your Values and Frame the Debate. White River Junction, VT: Chelsea Green, 2014. Also, Lakoff, George. 2006. Whose Freedom?: The Battle of America’s Most Important Idea. New  York: Farrar, Straus, and Giroux. 129  McIntyre, Lee. 2018. Post-Truth. Cambridge, MA: MIT Press. 130  McIntyre, 5. 127 128

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not occurring—that are made without any basis in fact. To these we can add other public debacles about mask wearing during a global pandemic, vaccinations, voter fraud, and continued claims that antagonize and distort race and gender in public policy. But where post-truth discourse differs from outright lying, McIntyre argues, is that post-truth is designed with intent to achieve specific purposes. “Those political shills who ‘spin’ the truth most favorably to their advantage…are not just bullshitting,” he writes, “for there is clear intent to influence others.”131 Similarly, Bruce McComiskey begins his 2017 essay, Post-Truth Rhetoric and Composition, by arguing that the past four years have seen “a shift in the way powerful people use unethical rhetoric to accomplish their goals; and … a shift in the way that public audiences consume unethical rhetoric.”132 While my own project is not a book about post-­ truth, I do assert, in agreement with McIntyre and Yaffa, that intention is embedded within deceptive policy arguments and that questions about intention can help to disaggregate the pragmatic agendas within such discourse. Post-truth, disingenuous framing, and directing intention are contemporary rhetorics coalescing within my project and within the contemporary remediation of intention. This ethical narrative complements the book’s assemblage of a more intentional humanities as noted above. For example, the discussion of genre theory in Chap. 3 considers how naturalized elements of rhetoric and composition may have contributed to forms of textual production that obscure intent and even incentivize writers to adopt a post-truth discursive context. Such pedagogy would seem to be incompatible with scientific and professional discourses and practices that privilege empirical data, practical consequence, validation, accountability, and intentional action. Moati writes that the debate between Searle and Derrida shows “the wealth and diversity of the discussions of intentionality in the twentieth century.”133 I might go further and suggest that intention was possibly  McIntyre, 9.  McComiskey, Bruce. 2017. Post-Truth Rhetoric and Composition. Boulder CO: University Press of Colorado. 133  Moati, 119. 131 132

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one of the most crucial and yet largely unmarked concepts for textual studies in the twentieth century. As we are currently seeing with discussions of post-truth, community responses to the COVID-19 pandemic, and the ongoing debates framed (at least in the United States) as culture wars, the importance of intention to discourse studies, public discourses, rhetoric, and professional communication has not gone away but is intensifying. I do not propose that examining intent will be a magic bullet or interpretive-analytic solution to post-truth. The problem is much more complicated and enduring. Yet, as Derrida concludes in Limited Inc, intention will have its place.134 Where this place exists, how it will occur, and what will be its productive significance I hope will be questions that animate this reading and future projects following my own.

 The full citation here is “In such a typology, the category of intention will not disappear; it will have its place, but from that place it will no longer be able to govern the entire scene and system of utterance [l’énonciation].” Derrida, 105.

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Bridge Gallery is pleased to present Secret History. Serbian Ionescu’s vision of Romanian folklore, alchemy and mythology mixed with reverberations of early childhood under Ceausescu’s Romania. A crossroads for the supernaturally tinged parts commingled with popular culture: hammer horror in one direction, utopian dreams that never were, in another, sinister resonances, uncanny dissonances and the world beyond…. In the midst of our time when purposeful intent is frequently considered dead, or if not dead then at least a failure at communicating anything of importance to society, works like Ionescu’s remind everyone about the vitality art can have in the service of an individualistic vision. – press release “Secret History” by Bridge Gallery, 98 Orchard St. NYC. Through 5/7/2012

In the mid-twentieth century, the humanities gave up intention as a formative concept. Historically seen as a productive component of rhetorical study, intention was not shelved without debate. But over the next 50 years, what became known as the intentional fallacy dismissed writers’ own accounts of their work. Here, autobiography and personal information about writers were cast as little more than distracting noise about the © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 B. Faber, The End of Genre, Postdisciplinary Studies in Discourse, https://doi.org/10.1007/978-3-031-08747-9_3

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meaning of literature and an author’s notes, correspondence, and interviews were subordinated to critical forms (historical, political, identity, economic, psychological) that could be superimposed onto a text into meanings potentially revelatory to even the author. Perhaps most frustrating for authors, even (or especially) a writer’s own opinions about how a specific work was produced, reasoned, or inspired had little influence on how that work was received, critiqued, or interpreted. What became known as “new critical” approaches emphasized the text’s aesthetic value as an end unto itself while other “reader response” orientations privileged the reader’s experience as the best insight into a text.1 To introduce a useful dichotomy, and foreshadow a discussion that we will return to later, truth (or empiricism) was exchanged for meaning, a slippery term that eventually and problematically became measured as significance.2 Dismissing intention resulted in an inability to differentiate among these terms or to critically recognize the differences between empirical finding and significance. To a degree, the intentional fallacy was a professionalizing achievement, especially in academic practices associated with literature and writing studies. Post-intention, textual questions and a critic’s authority were  For reviews see Eagleton, Terry. 1983. Literary Theory: An Introduction. Minneapolis: University of Minnesota Press. For economic and political criticism, see Williams, Raymond. 1990. Culture and Society. London: Hogarth (First edition by Chatto & Windus Ltd., 1958). See also, Tompkins, Jane. 1980. Reader-Response Criticism: From Formalism to Post-Structuralism. Baltimore: Johns Hopkins University Press; Iser, Wolfgang. 1980. The Act of Reading: A Theory of Aesthetic Response. Baltimore: Johns Hopkins University Press; Freund, Elizabeth. 1987. The Return of the Reader: Reader-Response Criticism (New Accents). London: Methuen; Davis, Todd and Kenneth Womack. 2002. Formalist Criticism and Reader-Response Theory. London: Palgrave Macmillan. On reader response criticism see especially: Fish, Stanley. 1980. Is there a Text in this Class? The Authority of Interpretive Communities. Cambridge, MA: Harvard University Press. Arguing against formalist interpretations that saw a text as its own objective authority, Fish argues that interpretive communities create meaning. As a consequence, textual meanings are dynamic, changing, and audience-dependent. 2  See, Rabinow, 2011, 178–184. Significance in this context does not refer to the mathematical or statistical concept but instead infers to the creation of something that receives notice. The criteria “receiving notice” can exist independent of ontological validity or what could be called truth or fiction and can stand in as a convenient proxy for meaning. Meaningful texts, in a capitalist democracy must be (more) popular. While there is a certain expedience in independently validating whether or not a text has received attention, such a metric splits and subordinates the accuracy of the text while simultaneously elevating its commodification. This is not so much an epistemological critique but a critique of how texts in certain disciplines achieve value. 1

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no longer imperiled by an impudent undergraduate student’s end-run around the professor (contacting an author to find out what a particular text “really means”). Interpretations generated by professional critics and researchers could now dismiss folk knowledge and amateur recollections as naïve accounts tied to local circumstances and limited times. The professional critic came to displace and claim the authority historically associated with the author. Intention did not go away quietly. Rear-guard arguments to preserve intention were offered perhaps most memorably by E.D. Hirsch and then in coauthored arguments by Steven Knapp and Walter Benn Michaels who asserted that any interpretation relies on authorial intention because they wrote, “what a text means and what its author intends it to mean are identical.”3,4 Knapp and Benn Michaels argued that there cannot be a distinction between textual meaning and authorial intention because interpretation necessarily ascribes intention when generating meaning. Alternatively, though they may not agree, Knapp and Benn Michaels’ argument could be construed to claim that the act of interpretation simultaneously constructs the author’s intention. The problem then becomes how do we know if the construction is accurate? Even if an author claims a certain intention, how do we know the author is being truthful? Joseph Margolis attempted to formulate a compromise of sorts by suggesting what he called a “robust relativism” in which the dichotomous finding of truth/falsity is appended by “plausibility.”5 Stating the

 Hirsch, Eric Donald Jr. 1992. In defense of the author. In Intention and Interpretation, ed. Gary Iseminger. Philadelphia: Temple University Press, 11–23. Originally published as Hirsch, E.D. 1967. Validity in Interpretation. New Haven and London: Yale University Press, 1–6, 44–48, 224–30. 4  Knapp, Steven and Walter Benn Michaels. 1992. The impossibility of intentionless meaning. In Intention and Interpretation, ed. Gary Iseminger. Philadelphia: Temple University Press, 51–63. Originally published as Knapp, S and W. B. Michaels. 1985. Against theory. In Against Theory: Literary Studies and the New Pragmatism, ed. W.J.T.  Mitchell. Chicago: University of Chicago Press, 12–18; Knapp, Steven and Walter Benn Michaels. 1987. Against theory 2: Hermeneutics and deconstruction. Critical Inquiry 14: 49–58. Knapp and Michaels have a larger project to destabilize hermeneutics as a critical strategy. See also discussion in Lyon, 40–48. 5  Margolis, Joseph. 1992. Robust relativism. In Intention and Interpretation, ed. Gary Iseminger Philadelphia: Temple University Press, 41–50. 3

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negative, he wrote, “falsity is opposed not only to truth but to plausibility.”6 Turning this around, in interpretive work, truth and plausibility, he claimed, could hold equal and simultaneous ground.

Meaning Without Empirical Referent This chapter examines the history of what became known as the intentional fallacy and how the concept grew beyond aesthetic studies into other forms of humanities scholarship including textual studies. This chapter argues that in rhetoric and in discourse studies, disinterest in intention occurred at the same time that interest in genre grew. In genre, the field was able to articulate the deployment of discursive forms and actions while eliding the problematics of intention. This chapter describes pedagogical and empirical consequences of eliding and naturalizing intention in writing studies and concludes by arguing that intention is closely tied to accountability, especially in public and professional discourses. Obscuring intention, especially in professional discourse, leads to alienation and cynicism in public discourses and has led to considerable public distrust with expert discourses. This lack of trust is further developed in Chap. 4, which considers calls by scientists for humanists to become more involved with social change, design, and an intentional science.

Chapter Summary To forecast where the chapter ends up, I argue that by introducing plausibility—truth and plausibility holding equal merit—Margolis introduced an important post-intention epistemological consequence. He wrote that unlike distinctly empirical questions of fact, interpretation allows a “curious tolerance” for simultaneous contradictions (“competing canons”) without any apparent loss of “rigor.”7 This space is created when  Margolis, 43.  Margolis, 42.

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the requirement for an empirical referent (the author’s intent) becomes bracketed and potentially negated by a plausible and potentially more important imaginative significance (the reader’s interpretation). For example, narratives, fables, sermons, movies, songs, and even anecdotes and aphorisms may be poignant and persuasive apart from any relationship to an empirical referent (what the writer intended). Margolis cited the origins of the solar system as an example-in-case. Multiple, simultaneous assessments suggesting how the solar system came into existence may be plausible at any point in time. Since we cannot physically experience the origin of the solar system, simultaneous accounts must offer “a procedure for determining the plausibility of causal hypotheses that is logically distinct from that of determining their truth.”8 Similarly, within human ecologies, stories, regardless of their truth or accuracy, can be both formative and motivational. Formal and informal narratives ranging from CEO pronouncements to coffee pot gossip, marketing discourse, customer feedback, email, and social media influence power, resource distribution, group membership, and change and stability.9 Scholars and reasonable people may disparage persuasion driven by inaccuracies and fictions but that does not mean that the consequences of these discourses should be ignored. For rhetoricians institutionally tied to English departments and whose careers and livelihoods were determined by literary critics, genre provided a practical, negotiated space for claims about discursive action, empiricism, and interpretation. Rhetorical scholars argued that regardless of a speaker’s intention, interpretation was still dependent on data, even if

 Margolis, 43.  For examples see: Faber, Brenton. 2002. Community Action & Organizational Change: Image, Narrative, Identity. Carbondale and Edwardsville, Southern Illinois University Press; Boje, David 2007. The antenarrative turn in narrative studies. In Communicative Practices in Workplaces and the Professions: Cultural Perspectives on the Regulation of Discourse and Organizations, ed. Mark Zachry and Charlotte Thralls, 219–237. Amityville, NY: Baywood. Boyce, Mary. 1995. Collective centering and collective sense-making in the stories and storytelling of one organization. Organization Studies, 16: 107–137. Czarniawska, Barbara. 1997. Narrating the Organization: Dramas of Institutional Identity. Chicago IL: University of Chicago Press; Henry, Jim. 2000. Writing Workplace Cultures: An Archaeology of Professional Writing. Carbondale and Edwardsville: Southern Illinois University Press. Dutton, Jane and Janet Dukerich. 1991. Keeping an eye on the mirror: Image and identity in organizational adaptation. Academy of Management Journal, 34:517–554. 8 9

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that data was prejudicial or ideological. Claims must have warrants, even if the warrant is implicit or naturalized by the discourse, context, or situation and rhetoricians saw it to be their role to identify these warrants. Margolis writes, “we can not detach such probabilized propositions from the evidence relative to which they are said to be probable.”10 As noted above, an agent may be persuaded to act by a fictional account, a song on the radio, or a social media post. Margolis’s compromise allows us to admit that the persuasion may have been interpretive, emotional, or fallacious while requiring that our account of the persuasion still be grounded in empirical data (what the agent heard that was persuasive). Plausible statements are motivational in aesthetic, scientific, and public policy forms. We find meaning and motivation in painting, sculpture, digital images, or game design. But crucially, Margolis teaches us that motivation is not the same as judgment and it is here that Margolis’ indulgence of plausibility ends but rhetoric’s problems with genre, empiricism, accountability, and public trust begin. When performing aesthetic criticism, Margolis writes, the professional writer is still accountable to an accurate description of the work and to what Margolis calls “admissible myths or schemes of imagination.”11 Genre theory accepted this limitation but conflated “admissible myths” with social exigency. Here, rhetoricians endorsed aggregations of form and action that used kairotic moments to influence persuasion while simultaneously obscuring intention. Genre studies both naturalized and elided the writer’s intention and over time produced a discursive context in which arguments, their consequences, and their meanings became three separate discursive functions. A consequence of eliding intention became a growing distrust between expert and public discourse and a retreat to discourses in which proxies took the place of evidence, argument, and empiricism.

 Margolis, 43  Ibid.

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The Intentional Fallacy W.K. Wimsatt and Monroe Beardsley’s essay “The Intentional Fallacy” was published in 1946 and reprinted as a revised version in 1954.12 The essay was derived from an entry they completed for the 1942 Dictionary of World Literature. Wimsatt and Beardsley defined intention as the “design or plan in the author’s mind.”13 Referring to their original entry in the dictionary, they provided their often-cited argument upfront, “We argued that the design or intention of the author is neither available nor desirable as a standard for judging the success of a work of literary art, and it seems to us that this is a principle which goes deep into some differences in the history of critical attitudes.”14 Wimsatt and Beardsley’s approach segments, or brackets, aesthetic criticism (“evaluating poems”) as a distinct and at the time unusual activity for literary scholarship.15 This important bracketing introduces a critical separation from historical, psychological, biographical, or political approaches to aesthetic work. Discussions about sociology, history, biography, or writing pedagogy may use novels, poems, or short stores, write Wimsatt and Beardsley, but they wish those practices to be distinct from aesthetic criticism.16 Regarding creative writing instruction they wrote, “All this would appear to belong to an art separate from criticism – to a psychological discipline, a system of self-development, a yoga, which the young poet perhaps does well to notice, but which is something different from the public art of evaluating poems.”17 “Author psychology,” “inspirational promotion,” “literary biography,” and “personal studies” all make the list of  Wimsatt, William K. and Monroe C. Beardsley. 1946. The intentional fallacy. Sewanee Review, 54: 468–488. Revised and republished as, Wimsatt, W.K. 1954. The Verbal Icon: Studies in the Meaning of Poetry, University of Kentucky Press, 3–18. The revised version (1954) responds to issues raised after the initial publication in 1946. The authors claim that they “raised the issue” but did not elaborate the discussion in a short article in the 1942 Dictionary of World Literature. The dictionary entry is, W.K. Wimsatt Jr. and Monroe C. Beardsley. 1942. Intention. In Dictionary of World Literature, ed. Joseph T. Shipley. New York: The Philosophical Library, 326–29. 13  Wimsatt, and Beardsley, 4. 14  Wimsatt and Beardsley, 3. 15  Wimsatt and Beardsley, 4 16  Wimsatt and Beardsley, 7, 9. 17  Wimsatt and Beardsley, 9. 12

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scholarship that, according to Wimsatt and Beardsley, may be “legitimate and attractive” but are practices crucially separate and distinct from the work of aesthetic criticism.18 The point of all this is two-fold. First, fully disjunctive from how it became applied, the prohibition against intention was raised as a specific criteria applied to a narrow form: interpreting the aesthetic value of art. Second, the injunction was prescribed as a way of making aesthetic criticism empirical and objective. If an author’s intentions are unimportant, irrelevant, and unobtainable, anything written about the text that uses an author’s intent as data cannot be empirically validated. In a passage echoing Plato’s Phaedrus, Wimsatt and Beardsley wrote that a work is owned by neither an author nor a critic. Writing is detached from the author at publication and the author has no ability to control how someone reads, appreciates, or understands it.19 As a consequence, modern students inherited an interpretive context in which intention became alternately irrelevant and unobtainable. At the same time, as intention became dismissed so did other fundamental components of humanistic inquiry. Ironically, Wimsatt and Beardsley’s hope for a more empirical basis for aesthetic criticism resulted in greater license for interpretation. The goal of reading and interpretation became significance rather than empirical fact and accuracy. That Wimsatt and Beardsley’s narrow prescription to exclude intention only in aesthetic interpretation became broadly accepted and influential across multiple interpretive disciplines seems to support their suspicion of intentional readings. Thus we re-encounter Plato’s larger ethical problem with writing: The meaning of a written text has no definitive, empirical referent: in aesthetics and literary criticism but also in politics, news reporting, philosophy, engineering, and science. As Jasper Neel puts it,  Wimsatt and Beardsley,10. Implicit in this argument is also the political/institutional claim for segmenting aesthetic studies in English departments from newly emergent fields such as rhetoric and composition, linguistics, writing, journalism, or more applied and professional pursuits. English was able to elevate and promote the institutional legitimacy of aesthetic criticism at the expense of other uses for and studies of the English language. Here, English became synonymous with literary criticism, a fairly recent development and segmentation in the field that has continued to persist. 19  See Plato. Phaedrus. Translated by Reginald Hackforth. Indianapolis: Bobbs-Merrill, 1952. 18

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“the text is always there for one more interpretation.”20 In this problematic, when a work “belongs to the public,” “embodied in language” an empirical referent is hard if not impossible to locate.21 Yet, Wimsatt and Beardsley are serious scholars who wish to impose greater accountability within their emerging professional discipline, “what is said about the poem is subject to the same scrutiny as any statement in linguistics or in the general science of psychology” they write.22 Data must be reproducible and must have evidence of integrity. As a solution to what has now become both an epistemological and professional ethical problem, Wimsatt and Beardsley argue that any data from outside the text itself is off limits. If a poem works, the text itself will provide the necessary and sufficient data to demonstrate that it works.23 Political, historic, biographical, geographical references not explicitly written in the text are therefore off limits.

Empiricism and Significance Thirteen-years after Wimsatt and Beardsley’s argument, E.D. Hirsch Jr. took stock of the by then successful and widely accepted intentional fallacy. By Hirsch’s account, the theory had “long been victorious” not only in literature studies, from where the prohibition had emerged, but also in other fields that located their data in texts.24 Hirsch wrote that fields as diverse as psychology (psychoanalysis), philosophy (Heidegger), linguistics, and information theory had, by the late 1960s, embraced in some  Jasper. Neel. 1988. Plato, Derrida, and Writing. Carbondale: Southern Illinois University Press, 19. 21  Wimsatt and Beardsley, 5. 22  Wimsatt and Beardsley, 5. 23  Though not the point of the current discussion, there is some irony here in that Wimsatt and Beardsley’s argument is epistemologically conservative and positivist as considerable scholarship citing the intentionally fallacy as motivational rejected these most modern concepts. Rather than turning to empirically validated data the fields associated with aesthetic literary criticism largely abandoned the concept of empirical data and positivist epistemology altogether. As Eagleton opines, “it provided a convenient pedagogical method of coping with a growing student population. Distributing a brief poem for students to be perceptive about was less cumbersome than launching a Great Novels of the World course.” Eagleton, 50, see also, 84–88. 24  Hirsch, 11. 20

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way what he called “the theory of semantic autonomy.”25 The theory necessitates that since texts appear independent of their origins and authors, a text’s meaning exists apart from what an author may have designed, caused, or wanted. Semantic autonomy, in Ricoeur’s words, “opens up the range of potential readers” for a text.26 Autonomy “severs” a text from its origins, opening text up to “an indefinite range of potential readers” and simultaneously an equally limitless range of potential interpretations.27 And that is exactly the problem Hirsch finds with abandoning intention. Hirsch’s criticism of the post-intention perspective was markedly prescient. He wrote, “it was not simply desirable that literature should detach itself from the subjective realm of the author’s personal thoughts and feelings; it was, rather, an indubitable fact that all written language remains independent of that subjective realm.”28 There is an odd doubling here regarding the concepts objectivity/subjectivity. Hirsch is troubled that literary studies (and textual studies in general) would leave behind the subjective realm, meaning what the author was thinking or feeling. His problem is that in leaving the subjective realm, literary criticism lost its objectivity—“it has also frequently encouraged willful arbitrariness and extravagance in academic criticism.”29 Hirsch continues, “and has been one very important cause of the prevailing skepticism which calls into doubt the possibility of objectively valid interpretation.”30 With the author’s perspective no longer relevant, critical interpretation has no “adequate principle” for determining validity or accurateness. As a consequence, the truth of a text, defined as what the author wanted to communicate, became not just impossible to determine but unwarranted and uninteresting.

 Hirsch, 12.  Ricoeur, Paul. 1976. Interpretation Theory: Discourse and the Surplus of Meaning. Fort Worth TX: Texas Christian University Press, 31. 27  Ricoeur, 35. 28  Hirsch, 11. 29  Hirsch, 12 30  Hirsch, 12. 25 26

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With the author’s purpose for writing no longer interesting, textual (artistic) meaning became individualized to each reader and purposefully arbitrary. Hirsch writes, “it became fashionable to talk about a critic’s ‘reading’ of a text, and this word became to appear in the titles of scholarly works.”31 Reading constituted a new class of professionals, the professional critic. Thus, “[t]he word [reading] seemed to imply that if the author had been banished, the critic still remained, and his new, original, urbane, ingenious, or relevant ‘reading’ carried its own interest.”32 Pushing this observation only slightly, the act of reading can become sufficiently original as to blur the distinction between fiction and its criticism.33 The mark of a good reading (interpretation) became the amount of attention the reading received (its significance), much like the commercial measures (stars, thumbs, awards) awarded to the same works being studied. For proponents, authorial intention provides empirical data that orients the researcher toward goals for validity, reproducibility, and determinacy. For Hirsch, the original author can be the only arbitrator to judge “real” versus “spurious” meaning.34 He writes that, “hermeneutics must stress a reconstruction of the author’s aims and attitudes in order to evolve guides and norms for construing the meaning of his text.”35 While a text may exist as a public product in the absence of the author, its meaning is composed retrospectively in relationship between public linguistic norms and the speaker’s objectives for communicating. Hirsch acknowledges that in many cases the author’s intentions may not be known or may be purposely withheld or obscured. In such cases, he writes, a text may remain ambiguous. But, such a finding remains empirical, reproducible, and determinate. “Ambiguity or, for that matter, vagueness” he reminds, “is not the same as indeterminateness.”36

 Hirsch, 13.  Hirsch, 13. In an effort to remain true to and simultaneously demonstrate the implications of Hirsch’s argument here, I left his pronouns as originally written. 33  Indeed, even as this chapter is a participant, criticism about criticism has become its own industry. 34  Hirsch, 15. 35  Hirsch, 17. 36  Hirsch, 21. 31 32

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There is some irony in the observation that Hirsch seems to support preserving interest in an author’s intention for pretty much the same reasons that Wimsatt and Beardsely disavow the concept.37 The empiricism (lack of external referent) Hirsch claims to be lost to semantic autonomy appears to be a chief motivator for Wimsatt and Beardsley’s rationale for the intentional fallacy. Meaning, in any context, can be a slippery concept to measure or validate. The meanings associated with actions, as Gary Woodward writes, place researchers within a considerable paradox. Even though motives and intentions are “central to who we are,” understandings about why they occur “are on the softest of ground of verifiability” Woodward concludes.38 Both the mathematical and the interpretive disciplines have used the term significance to separate findings that are noticeable. In both practices, significance articulates an ability to gain attention, to be noticed, to not be simply random (noise). Whereas the mathematical sciences have developed a quantitative method for determining such apart-ness, interpretive fields have had much greater difficulty determining significance and, as a consequence, assigning meaning to a text. Significance results from meaningful work. Yet, through a sort of expediency of valuation, significance can also stand-in for meaning especially once a field assuages an empirical referent.39

Obscuring Intention in Student Writing While Wimsatt and Beardsely may have been correct that an empirical reference for intention is hard to verify, their argument evokes a wider concern for empirical references for textual claims in general. While each

 As noted above, there is also some irony in criticizing Hirsch’s attempts to restore intention as “conservative” as that argument makes assumptions about Hirsch’s own intention. 38  Woodward xii. 39  Woodward puts it less delicately, “Accuracy [gets] lost to the habit of a quick scramble for talking points,” 44. 37

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critic sees intention (for different reasons) as a crucial component for authenticity in literary criticism, the implications of subordinating intention, as Hirsch predicted, have not been good for the humanities. To situate the current “crisis” in the value of the humanities fully within the rejection of intention would be overreaching.40 But, inasmuch as the rejection of intention signals a larger rejection of the empirical sciences, it becomes increasingly difficult to convince students and colleagues from empirical and technical disciplines to take seriously an activity in which any reading or interpretation could be considered adequate. Hirsch was correctly concerned that semantic autonomy left criticism without an adequate principle for evaluating its subject. He writes, One interpretation is as valid as another, so long as it is “sensitive” or “plausible.” Yet the teacher of literature who adheres to [the theory of semantic autonomy] is also by profession the preserver of a heritage and the conveyor of knowledge. On what ground does he claim that his “reading” is more valid that that of any pupil? On no very firm ground.41

As Hirsch predicted, modern students inherited an interpretive context in which intention became alternately irrelevant or unobtainable. Once the goal of reading and interpretation becomes to construct meaning, the evaluative context becomes arbitrary and ultimately capitalized in relations of significance: Things are meaningful if they are noticed. Without an objective way to evaluate or assess the meaning that is constructed, the act of constructing (a) meaning replaces value. With “no very firm ground” to claim that one reading is more or less valid, simply achieving a recognized form encodes writing as valuable. Take for example the generic opening sentences from the now clichéd undergraduate essay. Here we have a recognizable performance sufficiently problematic to stake a recognizable claim (achieve a modicum of

 For review, see Jay, Paul and Gerald Graff. 2012. Fear of being useful. Inside Higher Ed. https://www.insidehighered.com/views/2012/01/05/essay-new-approach-defend-value-humanities. Accessed 30 Dec 2021. 41  Jay and Graff, 13. 40

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significance) yet sufficiently general so as not to require substantive research. After all, even if the student-writer could propose a solution to global hunger, abortion, climate change, or race relations, there is no evaluative mechanism within the writing to assess the viability of the solution. Students soon realize this and become experts in producing a new, more nuanced take on the five-paragraph essay Jasper Neel called “anti-writing”42: Possibly the greatest challenge facing prosthetic limb developers today is to redesign the limbs that have become commonplace over the last sixty years. Heat has been always thought of as a wasteful product to scientists and engineers as it cannot do any work, but it is also a valuable resource for keeping us warm in cold winters. The benefits of a new altitude-training mask are controversial in the world of sports culture. Though high altitude training has been a well-versed concept in the past century, new masks may be detrimental to the overall health of the athlete. Solar power may be part of the solution to the looming energy crisis in the United States.

A well-placed hedge provides sufficient protection from a more knowledgeable reader; a global, timeless claim evokes common sense. The context suggests a topic large enough from which to generalize but limited enough to appear local. Embedded within this world of generalizations is a controversy designed for a specific and ready answer. The form of each introduction is interchangeable with the rhetorical context sufficiently generalized to bracket the contribution from any serious investigation of its actual material. There is nothing particularly wrong here and that is precisely the student’s achievement. So long as meaning (or in the cases above consequence) is generated and substantiated as an interpretive rather than empirical act, Hirsch’s complaint continues, there are very few grounds on which to evaluate one claim from another.  Neel cleverly evokes his own five-paragraph essay, “Three reasons for stopping X” writing, “X is one of the most important problems in today’s modern society. There are three main reasons why X should be stopped. This essay will explain those reasons” (84). 42

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The context for writing such papers requires the student to mimic an academic purpose and become an expert in articulating a false intention. Despite the rhetorical stance imposed on them by the assignment, students’ intentions here are rarely inspired by a new scientific discovery or engineering tool. Students are writing to achieve a good grade—or more to the point—to not achieve a poor grade. Such a task requires mediating available time against enough information to fulfill the assignment but not so much as to evoke a potential counter-argument or complication from the instructor. The point here is not that arguments from identity or experience are less legitimate than other arguments or motivations. An experiential narrative about training with a high-altitude-training mask could be vastly superior to a pseudo-scientific review. Nor is attempting to achieve a good grade a bad thing. But, lacking a complex discourse of intention, and worse, operating within a rhetorical practice that forces students to take on and employ false intentions, makes adequately understanding and evaluating rhetorical action and agency extraordinarily difficult and even unfair. Not only has textual theory subordinated intention, writing education has required students to mask, feign, and sublimate their own.43

 This is a chronic problem that cognitive research in rhetoric has yet to adequate address. Cognitive approaches to rhetoric demonstrated that intention is important to writing but could not articulate a complex or socially nuanced understanding of intention. Flower and Hayes may have been correct in a general way, that goal-directed thinking motivates effective writing but their model and approach are highly situated and problematic. Flower and Hayes wrote that intention translates middle-range goals “These middle-range goals, which lie between intention and actual prose … give substance and direction to more abstract goals (such as ‘appealing to the audience’) and they give breadth and coherence to local decisions about what to say next” (Flower & Hayes, 1981, 329). The problem is well-known at this point, Flower and Hayes, and later Wallace, assumed that their research subjects were genuine in narrating their speak-aloud protocols, in detailing their goals for writing, and that a writer’s intentions could be accurately mapped across specific hierarchical goals. The model also assumes that what people say in a protocol session accurately details unfiltered cognition. Recall that Wallace’s “useful intentions” consisted of a “consideration of how to meet the assignment criteria” (Wallace, 1996, 186). The approach misses the power dynamics between researchers (professors, graduate students) and students and it cannot adequately address non-linear writing processes, innovation, revision, or the social (human) intentions deployed during a writing session. The model’s narrow concept of intent—to meet the goals of an assignment— deploys a bias toward conformity, rule-governed behaviors, and genre replication and as such does not capture a robust or complex understanding of how intention informs discursive activities. 43

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The indeterminate nature of intention does not mean that text-based scholarship needs to abandon both the concept and the action of intention as a consequential component of postmodern argumentation. Equally, a naturalized comfort with indeterminateness does not necessitate the complete rejection of empirical data. After a period in which the argumentative form was dismissed as fallacious it seems that we lack a robust discourse that can discuss intention as something both empirical and subjective.

Restoring Intention Dennis Dutton reached a similar conclusion when he argued for a “systematic examination and restoration of the concept of intention in criticism.”44 Dutton acknowledges the epistemic and metaphysical constraints applied to and limiting intention as a critical concept. Epistemologically, as Beardsley and others have argued, it may be correct that we have little basis to know what an author’s intention might be. Perhaps a student writes a paper to better understand photovoltaic cell chemistry and has no interest in achieving a good grade. Or, perhaps the student’s intent is solely to meet an institutional prerequisite and calculates that it is easier to copy and paste from a roommate’s prior essay. The epistemic critique argues that the (unknowable) possibility of an author’s (stated) intention should not inform a determination of a successful text. Thus we typically assign and evaluate student work apart from what a student may intend to accomplish with that work. Metaphysically, Dutton notes, it has been argued that the concept of intention itself may not actually exist, that there may not exist a presence of mind purposeful or consistent enough to legitimately inform human

 Dutton, Dennis. 1987. Why intentionalism won’t go away. In Literature and the Question of Philosophy, ed. Anthony Cascardi, 194–209. Baltimore: Johns Hopkins University Press, 1987. http://www.denisdutton.com/intentionalism.htm 44

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action.45 Anscombe moderated this position suggesting that a hardline metaphysical position seems to overemphasize the expression of intention. She argues that this position limits intention as future prediction or desire, what Anscombe calls “a dead end.”46 Instead, Anscombe argues that intentional actions are distinguished and interesting because they “are the ones to which the question ‘why?’ is given application.”47 Intentional acts may then be those self-acts a person recognizes, in Anscombe’s terms, not just because [he or she] observed them.”48 Taking the two perspectives together, for example, knowing that a student intends to obtain a good grade rather than learn how to write about science helps to explain (both to the instructor and to the student) why a paper may have been written in a particular way, why a particular topic was chosen, and why the research was more or less comprehensive. Intentions, the stories we tell ourselves to justify action, occur in the spaces between fact and fiction, truth and meaning. Similarly, a more transparent discourse about intention would remove the student from the duplicitous role in which he or she must feign an intellectual intention in order to pursue the pragmatic one. Similarly, in professional and workplace contexts, if writing is (or can be) ambiguous, we should be teaching writers to explicitly state their intentions in their writing. In

 Dutton, 4. Yet, even after understanding and accepting both the epistemic and metaphysical positions, if the instructor discovers that the student deliberately copied the roommate’s paper, even if the paper is excellent, we still declare that the student’s intention is to cheat. The paper is a failure and the student expelled. Intention may lead to a slippery and convoluted path but, as Dutton notes, it still won’t go away. The actual cognitive existence of intention seems to be a more ready problem for philosophy than rhetoric. The point of the previous chapter was that even something that does not exist (a diagnosis) can have consequences for action. While philosophers may debate whether or not a plan of action based on wrongful information is a good, legitimate, or desirable thing, rhetoricians are more interested in understanding why and how that information was motivational. 46  Anscombe, 24. 47  Anscombe, 24. Anscombe’s definition in full states specific conditions under which the question “Why?” has relevance: “the question has not that sense that if the answer is evidence or states a cause, including a mental cause; positively, the answer may (a) simply mention past history, (b) given an interpretation of the action, or (c) mention something future.” Anscombe notes that in the cases (b) and (c) the answer to “Why?” provides a reason for acting. In case (a) the answer will get to motive (good or harm) (24–25). 48  Anscombe, 24–25. 45

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short, it might help to restore some of the integrity of the writing process and establish better accountability for written texts. Explicitly announcing intention helps explain action and behavior and it establishes an ethical claim to accountability even if the presumed intention is fictional, unknowable, or hard to admit.

Intention and the Problem of Genre There is a different way of arriving at Dutton’s “third way” to view intention. He suggests that the subordination of intention is more-or-less a genre problem. Genres, according to Berkenkotter and Huckin, are rhetorical forms that emerge in response to familiar, repeated (“recurrent”) situations.49 Genres encode and formalize task accomplishments. Once a text (or work of art) has been suitably accorded as/to a genre, intention (why the work was produced) becomes naturalized and can remain largely irrelevant. Dutton writes, “For once a categorical framework for understanding has been established (using intentionalist criteria), it might be argued that only then can criticism be undertaken (using nonintentionalist criteria).”50 Dutton looks to anthropological examples to explain that when encountering something new, without an interpretive context of “a standard repertoire of familiar genres,” we have to ask, “what is going on here?”51 After reasons for action are recognized, forms can be applied to bring together intent and action. Using Anscombe’s productive question, we no longer need to ask “why.” Merging form/action may create genres but this activity naturalizes intention and as such, genres also naturalize forms of production, accountability, and why texts are meaningful. Dutton writes, “…it is only by virtue of having so much familiarity with intentions that we can afford to disregard them and talk only of conventions.” Genres have been

 Berkenkotter, Carol and Thomas Huckin. 1995. Genre knowledge in disciplinary communication: Cognition/culture/power. Hillsdale NJ: Lawrence Erlbaum, 4–5. 50  Dutton, 6. 51  Dutton, 6. 49

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celebrated as recognized (significant) ways to get things done. Thus, they can operate well in an interpretive context in which meaning is tied up with recognition. Dutton continues, “[i]ntentions are thus not ignored by appeals to conventions; such appeals presuppose them.”52 An objective, empirical account of the writer’s intention is not necessary as the genre presumes such work. If a new genre is not yet recognized, it has little significance and thus is less able to presuppose the writer’s intent. Inversely, when we start to lose faith in genres, when such aggregations become stilted and commonplace, and when criticism and artistic impulse appeal to hybridity, change, innovation, and genre disruption, intention appears to (again) become more relevant.53 Dutton’s account of the subordination of intention to genre has historical and textual appeal. The academic disinterest in intention occurred simultaneously as genre criticism and later the rhetorical interest in genre came into its own. Textually, formal categories like irony and satire seem to categorically hinge on an author’s intention which is either subtly noted (in generic ways) within the text or is evident in extra-textual (deictic) references. Recognizing that genre naturalizes intention means that it also simultaneously complicates intention by allowing writers to mimic, suppress, or feign a generically coded intention. Here, genre stability seems susceptible not only to stagnation but also to an apparently purposeful polysemy. Correlating genre with social action, Carolyn Miller distinguished exigence from intention explaining, “exigence provides a rhetor with a socially recognizable way to make his or her intentions known.”54 For Miller, exigence provides “a sense of rhetorical purpose” contrary to intention, which “can be ill-formed, dissembling, or at odds with what the situation conventionally supports.”  Dutton, 6.  Berkenkotter and Huckin write, “A great deal has been written about the literary genres, and in rhetorical studies, genre theory has had a healthy resurgence since the late 1970s” (4–5). One can see in the last generation of rhetorical and cultural studies work a great deal of effort expended to locate spaces for action within genre theory—in accounts ranging from those that see genres as alternatively, social, action, dynamic, rhetorical, hybrid to larger more self-contained theoretical systems like activity theory and actor network theory. 54  Miller, Carolyn. 1984. Genre as social action. Quarterly Journal of Speech 70: 151–167. 52 53

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This sense of masking private interests within textual conventions seems to be what Dutton was getting at in his sense of naturalized intentions. But there is an ethical problem here. Miller claims that “in monologue, personal intentions must be accommodated to public exigencies—because the audience is larger, the opportunity for complex statement is greater, and constraints are less easily managed….”55 “Genre,” she later writes, “is a rhetorical means for mediating private intensions and social exigence.”56 Yet, by hiding intention, such advice would endorse rhetorical duplicity, masking intent with social exigence. We can see this played out in the term papers cited above in which students are being taught (and encouraged) a form that encodes a certain amount of intellectual performance (social exigence) where, in many cases, such aptitude does not exist (private intention). Yet, the essay, as a form, provides suitable generic salience to produce such affect. In other words, by simultaneously naturalizing intent and elevating significance over accuracy genres can provide useful but potentially suspicious (and ethically dubious) methods for getting things done.

Contrived Exigence: Situation and Intention Should we care if an adopted social exigence contradicts or masks personal intention? Lloyd Bitzer has argued that situation is constitutional (“the source and ground”) for persuasion and thus to rhetoric.57 “Let us regard rhetorical situation as a natural context of persons, events, objects, relations, and exigence which strongly invites utterance” he writes.58 Situation makes a discourse necessary, anticipated, and in a best-case scenario, expected. For Bitzer, rhetorical discourse is by definition persuasive discourse. Given this specification, situation co-constructs that discourse can be uttered (“rhetorical discourse is called into existence by situation”)

 Miller 1984, 162  Miller, 1984, 163. 57  Bitzer, Lloyd. 1968. The Rhetorical situation. Philosophy and Rhetoric 1: 1–14, 6. 58  Bitzer, 5. 55 56

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and what specific discourse may be spoken (“a fitting response”).59 “An exigence,” he argues, “is an imperfection marked by urgency; it is a defect, an obstacle, something waiting to be done, a thing which is other than it should be.”60 There are therefore numerous exigencies but Bitzer notes not all exigencies are rhetorical—only those exigencies that can be changed (persuaded) can be considered rhetorical. Bitzer’s account assumes that a situation naturally arises, “To say the situation is objective, publicly observable, and historic means that is it real or genuine—that our critical examination will certify its existence.”61 He contrasts situations “located in reality” from sophistic or contrived exigence, “spurious situations in which the existence or alleged existence of constituents is the result of error of ignorance.”62 He further distinguishes actual situations from fantasy and fiction. Bitzer recognizes that fiction may become “genuinely rhetorical” but he argues that occurs outside of the fictitious context and only if there is an actual relevant situation in which the fictional discourse can be deployed.63 Requiring students to invent a rhetorical situation apart from or antagonistic to their intention(s) would seem to be a pragmatic but contrived exigence. It promotes shifting meaning to a seemingly arbitrary and commercial sense of significance (generic or otherwise). The consequence of this has been the continued erosion of validity as a persuasive form and the displacement of validity in public discourse in favor of significance. Whereas scientists, philosophers, and policy makers argue that empirical facts should provide sufficient validation to change public behavior, various political classes, religious leaders, and public individuals have over and again situated competing beliefs, opinions, or faith statements as more significant than facts. Here, in the same way a student creates a fictional exigency for their term paper, opponents create alternative situations in order to insert a competing discourse. In such a context a

 Bitzer, 6, 9–10.  Bitzer, 6–7. 61  Bitzer, 11 62  Bitzer, 11 63  Bitzer, 11. 59 60

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student can independently validate generational changes in successive bacterium species, or theorize about species adaptation, yet simultaneously state she does not “believe” in evolution.64 To each situation the student has adopted her own rhetoric. The problem arises when we force people to choose among situations. Kahan, Jenkins-Smith, and Braman documented this phenomenon when surveying respondents about climate change.65 Working from what they called “the cultural cognition of scientific consensus,” Kahan, Jenkins-­ Smith, and Braman found that people would consider controversial topics in ways that created and protected affinity within their social groups. These rhetorical actions avoided conflict within peer groups, protected hierarchy, and promoted that individual’s social standing within the group. Kahan, Jenkins-Smith, and Braman showed that an individual’s perceptions about issues as diverse as climate change, gun control, nanotechnology, and nuclear power seemed motivated primarily by peer group cohesion rather than scientific reporting, scientific consensus, education, or self-discovery. Thus, they write that when considering an issue like climate change, “individuals will more readily recall instances of experts taking the position that is consistent with their cultural predisposition than ones taking positions inconsistent with it.”66 Even the term “expert” is more readily attributed to those who share a worldview, sustain local connections, or are in a position to advance an individual’s self-interest. Bitzer was prescient if perhaps optimistic. Writing about compelling historical situations, he argued, “one cannot say that the situation is the function of the speaker’s intention for in this case the situation is the function of the speaker intention.”67 Situations do call for specific discourses and those situations may require particular rhetorical purposes. But intention in such exigencies is more abstract and fluid. People use situation to enact intentions that are apart from what a situation

 Personal conversation, Karen Oates.  Kahan, Daniel, Hank Jenkins-Smith, & Donald Braman, 2011. Cultural cognition of scientific consensus. Journal of Risk Research: 147–174. DOI: https://doi.org/10.1080/1366987 7.2010.511246. 66  Kahan, et al., 149. 67  Bitzer, 9. 64 65

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determined—using climate change as a proxy for group cohesion, fundraising, or institutional and community power. Alternatively, agents have naturalized Bitzer’s contrived exigence, purposefully constructing situations in order to deploy unrelated intentions. “Never let a crisis go to waste”—real or contrived—has thus become the new public policy maxim.68

“ The Self Is at Stake” Intention, Alienation, and Significance These problems become even more complicated in interpretive disciplines. As Rabinow notes, in a democratic culture, we hold that citizens are ultimately able to arbitrate cultural affairs. While it has become increasingly difficult for an average citizen to arbitrate the meaning of work in the natural sciences, when scholarly inquiry directly concerns wider cultural phenomenon (literature, film, creative work, rhetoric), meaning has become interpolated as significance: appeal, audience reception, readership, and popularity.69 As a result, people are more likely to seek out information that conforms to their already-held beliefs, or attend to information from peers and peer group leaders, people who can arbitrate significance. Without an evaluative framework for evaluating empirical claims, when scientists, scientific publications, or scientific news do not conform to an individual’s predispositions, the empirical claims are regarded suspiciously or as biased.70 Richard Harvey Brown has explained that such strong identification, even in the face of overwhelming empirical data, can be attributed to an  While the original source of the quote is disputed, it has been popularly associated to Rham Emanuel and Winston Churchill. M.  F. Weiner used the phrase “Don’t waste a crisis—your patient’s or your own” in the journal Medical Economics 53: 227. 69  See discussion in Rabinow, 2011, 182–183. Rabinow works from Max Weber’s essay, “Science as a vocation” published as: Weber, Max. 1946. Science as a vocation. In From Max Weber: Essays in Sociology ed. and trans H.H.  Gerth and C.  Wright Mills. New  York: Oxford University Press, 129–156. Originally published as Weber, M. 1922. Wissenschaft als Beruf. In.Gesammelte Aufsaetze zur Wissenschaftslehre. Tübingen, 524–55. 70  Rabinow, 2011, 150. 68

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increasing sense of alienation people feel in modern cultures aligned with globalization and rational systems.71 Brown argues that global market and awareness have simultaneously introduced greater diversity but encouraged monoculturalism and isolationist backlashes. This is because racial, religious, ethnic, and gendered identities are perhaps more consequential (significant) to an individual and less transient and less likely to change than economic, policy-driven, or science-based claims. In such contests, “the self is at stake” writes Brown, as the rhetoric (strategically) transposes “what do you think” into “who are you?”72 The categorical notion of “belief” slides between accepted scientific first principles and religious commitment with all its consequences for ethnicity, family, and the afterlife.73 The resulting dynamic of the rhetorical situations described here is that generic responses to contentious issues encode one intention while performance enacts a different and unrelated intention. For example, as Kahan, Jenkins-Smith, and Braman showed, individuals dispute scientific findings about climate change, not because those individuals have passionate concerns about climate but because they want to maintain peer-group membership and cohesion. For the most part, espousing a belief in evolution, denying sea level rise, disputing nuclear power, or arguing for-or-against deep sea oil drilling rarely has much effect on an individual’s day-to-day activities.74 However, peer-group membership can be essential to managing a household, getting and keeping work, community, friendships, and even business transactions. While the genres  Brown, Richard Harvey. 2005. Culture, Capitalism, and Democracy in the New America. New Haven: Yale University Press, 19. 72  Brown, 57. Brown makes the illustration with the questions “Which side are you on?” and “What are you?” 73  Brown (59) writes that with greater materialist freedom, the middle class no longer identifies as an economic unit. Citing Bourdieu he notes that a small business owner and a liberal arts professor may have similar incomes but have vastly different politics, status markers, and influential peer groups. In this way the middle class becomes a fractured political group identifying with new and diverse social rather than economic markers. These markers have tended to aggregate together in ways that Kahan, Hank Jenkins-Smith, and Braman subsequently have identified. 74  Unless one’s life is directly influenced by these issues, see, for example, efforts to contain and reverse sea level rise in Florida: http://www.de,state.fl.us/oceanscouncil/reports/Climate_Change_ and_Sea_Level_Rise.pdf (last accessed 5/27/2015); http://www.pbs.org/newshour/extra/daily_videos/south-florida-considers-investing-in-infrastructure-to-combat-rising-sea-levels/ (last accessed 5/27/2015). 71

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of scientific debate encode specific intentions, especially among experts, the generic responses to these issues among non-scientists appear to be performed for entirely unrelated intentions.75 In these cases, intentions are important and as part of genre-deployment potentially more crucial than the social exigence performed or invented. Without a discourse of intention to get to the “whys” performed here (group cohesion, tribal alliance) issues with great environmental and social salience cannot be brought to democratic fluency. Instead, they persist as wedge issues with implications not for the issue under consideration (sea level rise, health care, public safety) but for group exploitation. If we hope to solve these problems and restore a useful dialogue to public policy, we should care if social exigence contradicts and masks personal intention. The aggregation of form and action as a discursive construct was offered as a way to encode relatively stable communicative forms that enabled purposeful action. In this way, scholarship (and the concept of genre) remained conceptually tied to empiricism largely through the concepts of speech acts and performatives.76 Forms are performed in business (letters, memos, resumes, proposals), the professions (doctor-patient consultations, scientific reports, legal briefs, judicial statements), and in social occasions (weddings, funerals, graduations) and have been documented as not simply fictions but as accomplishing actual tasks in real situations. However, by over-emphasizing the social exigence of performance, genre seems less able to accommodate strategic shifts from empirical enactment to significance: people using discourses not so much to solve a problem or complete an action but as placeholders for identity, group formation, economics, and power. Here, the inability to differentiate empirical findings from significance becomes inverted when we mistake performance (significance) for empiricism (truth). This is not to hold a new interest in intentionality up to the empiricism of Wimsatt and Beardsley nor even that evoked by Hirsch. The intention deployed

 Except that one could argue that the creation of consensus within academic disciplines achieves the same sort of group identity that can also override empirical findings. 76  Foundational scholarship reflects the empirical emphasis in genre studies, see for example, Austin, 1962, 1975 and discussion in Chap. 2. As review, Austin’s concept of the performative accomplished empirical acts: becoming married, naming a ship, bequeathing a will, establishing a bet. 75

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here suggests a slightly different relationship with empiricism. Here, a text is no longer autonomous as Wimsatt and Beardsley would have it, but understood by what that text accomplishes. Precisely why a text would appear meaningfully significant (as opposed to empirically accurate) in a specific deployment marks an empirical question to help pursue intention. Perhaps, in the pursuit of intention, we need to disaggregate (again) forms from actions. A new, post-genre rhetoric creates and performs discourses able to de-­ naturalize those intentions coded within generic performances. A post-­ genre rhetoric also recognizes that an ambiguous intention, especially one elicited by professional writers or professional discourse, is not exculpatory. Professionals have an obligation to be accountable for their communication. By naturalizing intention, genres can obscure the potential for empirical verification of motive, action, or consequence. Genres can also obscure the local sites where meaning is produced. A narrow emphasis on genre can take an accounting of intention off the table. In effect, genre has conveniently allowed rhetorical scholarship to simultaneously study action (performance) without necessitating a concomitant discourse of intention.77 Three decades into this project, perhaps we can ask to what extent has sidestepping around intention enabled a certain distraction away from rhetorical manipulations? To what extent has genre enabled a naturalization of Bitzer’s “contrived exigence” in the pursuit of unrelated intentions? Perhaps the strategic deployment of genre has pushed such aggregations to a point where they are no longer helpful for understanding, encoding, and facilitating human action. Intention, as an alternative aggregation of form/action, may yet get a good dusting off when we more thoroughly recognize and pursue how individuals and groups strategically deploy forms for contradictory and manipulative purposes.

 Hirsch offers a political question and critique when he writes, “It is a task for the historian of culture to explain why there has been in the past four decades a heavy and largely victorious assault on the sensible belief that a text means what its author meant” (11). Inherent within Hirsch’s statement is a similar troubling question regarding the politics inherent within the concept of genre and the widespread acceptance and promotion of genre scholarship. 77

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Conclusion: Rereading the Intentional Fallacy D. F. McKenzie, in his Bibliography and the Sociology of Texts, presents an alternative reading of Wimsatt and Beardsley’s “Intentional Fallacy.” McKenzine’s reading begins with the epigraph that opens Wimsatt and Beardsley’s essay, a selection of verse from Congreve’s (1700) prologue to The Way of the World.78 McKenzie reports that Wimsatt and Beardsley misquote the first line of Congreve’s verse. While McKenzie’s version reads “He owns, with Toil, he wrought the following Scenes, / But if they’re naught ne’re spare him for his Pains”: Wimsatt and Beardsley’s version reads, “He owns with toil he wrote the following scenes; /But, if they’re naught, ne’er spare him for his pains.” Stylistically, McKenzie notes, the change appears strange since it alters the subsequent rhyme and the cohesion the rhyme builds with the second line. McKenzie also notes that the punctuation has been changed, the commas surrounding “with Toil” have been eliminated. Further, in a second couplet, Congreve wrote, “Damn him the more; have no Commiseration / For Dulness on mature Deliberation” while Wimsatt and Beardsley misquote, “Damn him the more; have no commiseration/For dullness on mature deliberation.” Noting the comma drops around “with Toil” McKenzie writes, “By isolating and emphasizing the phrase, Congreve may be read as affirming his seriousness of purpose, the deliberation of his art.” By dropping the commas, “Wimsatt and Beardsley speed past it, their eyes perhaps on a phrase more proper to their purpose in the next line.” McKenzie

 See note 85 above. McKenzie, 19–29. I would like to thank Miles Kimball for recommending McKenzie’s work. The full epigraphs are as follows: 78

Wimsatt and Beardsley’s version: He owns with toil he wrote the following scenes; But, if they’re naught, ne’er spare him for his pain: Damn him the more; have no commiseration For dullness on mature deliberation.

Congreve’s version (1710) cited by McKenzie: He owns with Toil, he wrought the following Scenes, But if they’re naught ne’er spare him for his Pains: Damn him the more; have no Commiseration For Dullness on mature Deliberation.

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continues in this way to show deliberate, if apparently minor, changes from one text to another, a loss of comma here, dropping a capital letter there. But, the accumulated evidence demonstrates that Wimsatt and Beardsley’s version has Congreve saying exactly opposite of what the original text would have meant. McKenzie writes, By reducing all his nouns to lower case and thereby destroying the early eighteenth-century convention, the epigraph kills off Congreve’s personified forms, and by muting his irony, it reverses his meaning. Where Congreve’s irony contrasts his own ‘mature Deliberation’ with the ‘Dulness’ of his critics, their meaning has him saying the reader knows best.79

Further, McKenzie writes, “one set of meanings, which stress a writer’s presence in his work, is weakened in favour of a preconceived reading which would remove him from it.” In McKenzie’s reading, Congreve’s ownership of his text and his meaning is consistent with Congreve’s other work, the work of his mentor Ben Jonson, and the perspective of other writers at his time. But McKenzie also writes that Wimsatt and Beardsley’s misreading is also historically consistent with what Wimsatt and Beardsley argued in other venues, with what their peers argued, and the formalization of literary studies at the time. “In that context, the misreading of Congreve in 1946 may be seen as almost a matter of historical necessity, an interesting document itself in the nature of reading and the history of the book” McKenzie writes.80 In other words, Wimsatt and Beardsely may not have been wholly accurate, but their argument was meaningful for the way it propelled forward a new way of reading, a new field of aesthetic criticism, and a new, elevated role for the critic. In these ways, the argument against intention was ironically successful for what it intended to accomplish even if it was based in an empirical misreading. What McKenzie offers seems similar to the “robust relativism” advocated by Margolis. By investigating the author’s intention, McKenzie shows that it is possible to simultaneously consider multiple competing

 McKenzie, 21.  McKenzie, 26.

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claims and still ground inquiry in empiricism. McKenzie shows that questions about intention are not necessarily reductive but in his words make textual scholarship “secular.” “In the ubiquity and variety of its evidence, bibliography as a sociology of texts has an unrivalled power to resurrect authors in their own time, and their readers at any time,” he concludes. “One of [bibliography’s] greatest strengths is the access it gives to social motives: by dealing with the facts of transmission and the material evidence of reception, it can make discoveries as distinct from inventing meanings.”81 Did Wimsatt and Beardsley’s intentionally alter Congreve’s text? For McKenzie, and for us, this is the wrong question. First, McKenzie suggests that Wimsatt and Beardsley’s probable source for the epigraph included the errors.82 But, given the historical and institutional expectations for literary studies in 1946, and for New Criticism as an emerging perspective, Wimsatt and Beardsley’s misreading was intentional in that its action further instantiated a way to interpret literature by removing the author from the equation.83 McKenzie’s own presentation here, his effort to, in his words “show it up” is also intentional as McKenzie is writing to replace decontextualized reading with sociological bibliography. In both cases, questions of intention ask us to examine and be accountable to the performative aspects of the text, what the text is doing, and, as Anscombe asks, why it appears to be doing it. Examining textual performance thus displaces questions of significance and meaning and instead asks us to investigate and validate how a text is alternately taking advantage of a situation or why it may be deliberately creating a new one.

 McKenzie, 29.  McKenzie, 27. McKenzie writes that the probable source for Wimsatt and Beardsley’s epigraph was an anthology of plays edited by Nettleton and Case. McKenzie argues, via an essay in The Times Literary Supplement by Tzvetan Todorov (4 October, 1985), that “the dominant tendency of American criticism is anti-humanism” (29). Thus, the movement to exclude intention from critical reading coincided with a movement in the field against its own humanism. McKenzie offers that by “showing the human presence in any recorded text” bibliography has “a massive authority with which to correct that tendency” (29). 83  Or, perhaps Wimsatt and Beardsley’s Modernism could not fully leave behind a Romantic hope for imagination and transcendence. 81 82

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“After” can alternatively evoke several functions. First is the most common temporal function referring to something happening in temporal succession: the “post-” construction of the term, “she arrived after the movie started.” Second is a function of resemblance or inheritance, a name that recalls a prior person, “she was named after her mother” or a style inspired by an existing or prior aesthetic “a building modeled after the Chrysler Building.” Third is a function that denotes a quest or pursuit, “the detective chased after the suspect.” As a temporal claim, the contemporary humanities largely occur in a time in which intention no longer seems to matter. But to switch from temporality to pursuit, so long as we are after intention, further experiments are required.

4 Design: Nanotechnology and the City

We are closer to a science of intentional change than one might think. —David Sloan Wilson, Steven C. Hayes, Anthony Biglan, & Dennis Embry Microbiology is the new agriculture, domesticating new life forms. —J. Bruno-Barcena

The previous chapter claimed that modern approaches to textual studies might have been too quick to dismiss intentionality. Textual studies’ suspicion of intentionality was inherited from literary studies and the promotion of the “intentional fallacy” which suggests that we cannot settle any question about the meaning of a text or performance by asking the author. Yet, intention remains important for the ways its study can weave together meaning, production, and accountability outside the forms and autonomous conventions enacted by genres. Studying intention can situate meaning at its most granular levels of production. The previous chapter also claimed that there is an ethical project here. By naturalizing and eliding intention, genre theory has allowed an emphasis on social exigence over production, significance over meaning, and a duplicity that can lead to alienation, suspicion, and cynicism about public discourse.

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 B. Faber, The End of Genre, Postdisciplinary Studies in Discourse, https://doi.org/10.1007/978-3-031-08747-9_4

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This chapter points out that colleagues and practices in science and engineering disciplines are largely oblivious to the debate about intention and operate according to protocols designed specifically to evoke and accentuate intentional and replicable forms and events. As currents in the humanities attempted to excise meaning from local production, this work created a perspective and a relationship to knowledge that distanced questions, perspectives, and outcomes from considerably different practices in the physical sciences. This divide has created incommensurability among disciplines and made mutually constituting collaborative work, especially between humanities-based approaches and those emerging from science and engineering, nearly impossible. While debate about subordinating authorial intention appears to be now naturalized in humanist discourses, a similar subordination did not occur in the natural and physical sciences. Instead, intentional discourses, in forms both legitimate and less so, became a constitutive component of modern science. Such discourse overtly (if disingenuously) positions the researcher as a deliberate actor announcing and pursuing an explicit intention. As a consequence, knowledge production in the humanities has become both operationally and rhetorically significant in ways crucially different from the empirical sciences.

 hapter Background: Intentionally C Designed Spaces This chapter emerged from a multi-year project that traced the emergence and instantiation of a supposed new field within the sciences (nanoscience, nanotechnology). The project had the opportunistic benefit of timing. From roughly the years 2000 to 2010, the dual terms nanoscience and nanotechnology, opposite sides of the same coin, accrued new courses, scientific papers, journal titles, books, academic departments, institutes, and centers, and at the national level, National Science Foundation grants and directorates, and a National Nanotechnology Initiative. In 2004, Merrill Lynch launched a nanotechnology index fund. These events offered the rare opportunity to witness a field emerge and compete for legitimacy in real time. With our own support from the

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NSF, my research team aggregated every written mainstream (popular) media article about this new effort as proponents sought to capitalize on the new initiative. Commencing with a 1986 article, titled “Tinytech” by Fred Hapgood in Omni magazine, the study extended through December 2000. The project started with 885 articles. Restricting the textual sources to newspapers, general interest magazines, and popularized science publications and eliminating duplicates resulted in 203 articles. The study was motivated to better understand the concept of “the new” as it applied to a new field in science. We wanted to examine how a “new” science is created within and against existing disciplines and how something like nanoscience “emerges” and is “instantiated” within existing and competing disciplinary and social networks.

Nanotechnology: From Micro to Macro For reference purposes, a nanometer is roughly one-billionth of a meter. Various sources claim that a human hair is between 50,000 and 100,000 nanometers in diameter.1 Much of the emergent work that called itself nanoscience and nanotechnology (from this point on, simplified as “nanotechnology”) derived from a speech Nobel Prize-winning physicist Richard Feynman gave in 1959 titled “There’s plenty of room at the bottom.”2 In his speech, Feynman considered the construction of matter from the molecular level up. Atoms would be placed side by side and through chemical synthesis any substance and material could be created. From Feynman’s speech until the mid-1980s, molecular manufacturing was still speculation. The 1980s saw three significant developments in nanotechnology that made Feynman’s predictions more possible. In 1980, Gerd Binning and Heinrich Rohrer at IBM’s Zurich Research  http://www.nano.gov/nanotech-101/what/nano-size  Feynman, Richard. 1959. There is plenty of room at the bottom. Presentation to the American Physical Society, Pasadena CA. Dec. Available at: http://nanoparticles.org/pdf/Feynman.pdf. For more information on the history of nanotechnology (nanoscience), see: Eric Drexler’s blog Metamodern http://metamodern.com/lost-history/. Accessed 15 July 2015; Faber, Brenton. 2006. Popularizing Nanoscience: The public rhetoric of nanotechnology 1986–1999. Technical Communication Quarterly 15: 141–169. 1 2

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Laboratory introduced the scanning tunneling microscope, and in 1985 Binning invented the atomic force microscope. These two technologies allowed scientists to observe and operate at the atomic level, creating the possibility for the purposeful manipulation of atoms, what became known as nanotechnology. In 1985, Richard Smalley and Robert Curl at Rice University and Sir Harry Kroto of the University of Sussex discovered a new form of carbon that they called a “buckyball,” as its structure mirrored the domes created by inventor Richard (“Bucky”) Buckminster Fuller. Buckyballs soon became the image and principle marketing tool of the nano-industry, as scientists and engineers used them to study the formations, structures, and potential within molecular-level work. Eric Drexler’s 1986 book, Engines of Creation: The Coming Era of Nanotechnology, did much to popularize the field, and throughout the late 1980s and early 1990s a variety of discoveries helped to fuel the scientific community’s interest in nanotechnology.3 In 1988, chemists at AT&T Bell Labs demonstrated that molecules behave differently at the atomic level, contributing to claims in quantum mechanics that theorized this effect. In 1990, IBM scientist Don Eigler formed the IBM logo out of xenon atoms, demonstrating to other scientists the potential for exact manipulation of atoms at the molecular scale. This demonstration was followed by the creation of carbon nanotubes, which demonstrated that atoms could be shaped in different ways at the molecular level. Shaping atoms in different ways at the molecular level led to speculation that atoms with different geometries could be used as atomic-sized building blocks. The early promises and predictions for nanotechnology were broad ranging and spectacular. Buckyballs were found to be incredibly strong and resistant to crushing, impacts, and collisions. As hollow cylinders they were theorized to be a perfect molecular transport container for pharmaceuticals. Ideally, a drug could be placed inside a buckyball composed of a special tracer material. A virus, bacteria, or cancer cell would attract and absorb the tracer with its payload. Once absorbed, the nanotransport device would release the dosage directly inside the pathological target.  Drexler, Eric. 1990. Engines of Creation. The Coming Era of Nanotechnology. New York: Anchor. (Originally published 1986). 3

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Nanotechnology’s actual initial commercial applications were most prominent in electronic computer memory technology and polymer coatings. Such applications largely derived from the creation of carbon nanotubes. Nanotubes are created by rolling sheets of graphite into cylinders. The resulting tubes are highly conductive and strong. However, a good deal of this technology was not new and had been in use for several decades. For example, much of the work in nanoscale electronic memory storage intersects with micro-electrical-mechanical systems (MEMS) technology, which applies molecular layers onto silicon to integrate mechanical elements, sensors, and other electronics. In polymers, molecular-­sized particles have been blended and layered on surfaces since the 1960s. The “new” applications of nanotechnology in polymers included resins, catalysts, and varnishes in automobile manufacturing. Applications in textile research included water- and stain-resistant materials, anti-microbial fibers, chemical and biological detection, and UV filters. A good deal of application was found in the cosmetics industry including skin hydration, UV protection, and chemical encapsulation technologies for depositing substances under the skin.4 These useful, if modest, applications of nanoscale research are far removed from the claims made by nanotechnology advocates. In the public media, nanotechnology has been associated with cryogenics and the repair of damaged (or dead) cells, a cure for cancer, self-repairing highways, bulletproof clothing, pharmaceutical delivery systems, direct-­ cell targeting disease applications, and affordable, abundant energy.5 The promises of nanotechnology also sparked an oppositional discourse cautious about the very forms proponents were advancing. Opponents coined the term “grey goo” to refer to intelligent swarms of nano robots with the size and predatory nature of a virus.6 Other writers have predicted that toxic nano-size particles disposed into wastewater would  Hearn, Kelly. 2003. The next big thing (is practically invisible): Nanoparticles—objects on a scale of one-billionth of a meter—now turn up in everyday products from tennis balls to sunscreen. Christian Science Monitor, March 24, 17. 5  See for example: Drexler, 135; Berger, Eric. 2003. Science of the tiny: Nanotechnology enthusiasts laying path for innovation. Houston Chronicle, March 2, A1; Economist. 2003. The wizard of small things. Economist. March 15, 31–32. 6  Radford, Tim. 2003. Brave new world or miniature menace? Why Charles fears grey goo nightmare: Royal Society asked to look at risks of nanotechnology. Guardian, April 29, 3. 4

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avoid pollution filters and seep into skin and vital organs of fish and predators, or into the soils and cellular structures of crops, and ultimately poison humans.7 In April 2003, the Eco-Equity Erosion, Technology Transformation and Corporate Control (or ETC) Group, a Manitoba-­ based organization, became the first advocacy group calling for a moratorium on the manufacture of synthetic nano-particles created in the absence of health, safety, and environmental impacts (ETC).8 These concerns are not unfounded. A 2008 study reported that mice exposed to carbon nanotubes developed pathological conditions similar to those resulting from asbestos exposure.9 Low concentrations of buckyballs were found to be fatal to water fleas, nanoscale carbon is absorbed through the gills of large-mouth bass and pass through the blood-brain barrier causing neurological damage. Carbon nanotubes cause delays in zebra fish hatching, aluminum nanoparticles have caused a reduction in root growth in crops, and silver nanoparticles in wastewater have killed good bacteria used to treat sewage.10

Rehabilitating Space: From Macro to Micro Paul Rabinow has described such rehabilitation and rationalization of space as a uniquely modern project. At a different scale and a prior time, massive projects of urban design, civil engineering, land reclamation, and space making not only disrupted and redesigned the physical landscape but introduced distinct and novel ways to think about action, intention,  Feder, Barnaby. 2002. Nanotechnology has arrived; a serious opposition is forming. New York Times, August 19: A3. Feder, Barnaby. 2003. Research shows hazards in tiny particles. New York Times, April 14: C8. 8  Eco-Equity Erosion, Technology Transformation, and Corporate Control Group. 2005. Special report: nanogeopolitics: ETC Group surveys the political landscape. Retrieved online http://www. etcgrou.org/content/special-report-nanogeopolitics-etc-group-surveys-political-landscape. Accessed. 15 July 2015. 9  Poland, C., et al. 2008. Carbon nanotubes introduced into the abdominal cavity of mice show asbestos-like pathogenicity in a pilot study. Nature Nanotechnology 3: 423–428, doi: https://doi. org/10.1038/nnano.2008.111. 10  Murty, B.S., et al. 2013. Textbook of Nanoscience and Nanotechnology. Bangalore, India: Universities Press, 222; See also, Kewal Jain. 2008. The Handbook of Nanomedicine Basal, Switzerland: Humana Press/Springer, 339. 7

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and the human ability to redesign nature and the physical world.11 Citing Georges Canguilhem, Rabinow describes what he calls “a distinctly French concern” in the life sciences of the nineteenth century. This was “a belief that living beings and their milieu have no predestined harmony but are fated to struggle, through a disciplined and relentless effort of will, to adapt to constantly changing circumstances.”12 This cognitive impulse toward a “relentless effort of will” extended beyond French rationality to other colonial powers, activities, and locations. Civil engineering at the macro scale of dams and levees, seaways, and transportation networks emerged from and furthered a disposition to science and space that is not so different from the impulses and ways of thinking now evident in the twenty-first century discourses of nanotechnology.13 Across these scales, the global and the nano, modern science is being transformed by technological intention into new forms of manipulative practice. A romantic science iteratively constructed from description and categorization has turned into the intentional manipulation of space. To an extent, science as practice is not new: What is nanotechnology if not an updated revision of alchemy? Yet, as nanotech and other new manipulative sciences in proteomics, genetics, and synthetic biology engage the human at new levels of intimacy and violation they also instantiate a much more deliberate and rationalized formation of intention and agency. Such a perspective forecasts what David Sloan Wilson, Steven Hayes, Anthony Biglan, and Dennis Embry have called “a science of intentional change.”14 Their article, titled, “Evolving the future: Toward a science of intentional change” was published by Behavioral and Brain Sciences in 2014. The article reads as a manifesto, complete with examples of scientifically guided interventions designed to evoke changes in individual and group behaviors. Recognizing the potential interest and  See for example, Caro, Robert A. 1974. The Power Broker: Robert Moses and the fall of New York. New York: Alfred A. Knopf; Alexander, Jeff. 2009. Pandora’s Locks: The Opening of the Great Lakes-St. Lawrence Seaway. East Lansing: Michigan State University Press. 12  Rabinow, Paul. 1995. French Modern: Norms and Forms of the Social Environment. Chicago and London: University of Chicago Press, (originally, published 1989, MIT Press), 13–14. 13  We can add here additional pursuits in genetic modification, protein manipulation, and amino acid interventions. 14  Wilson, David S., Steven Hayes, Anthony Biglan, and Dennis Embry. 2014. Evolving the future: Toward a science of intentional change. Behavioral and Brain Sciences 37: 395–460. 11

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reaction to a proposal to use scientific understandings of evolution and evolutionary methods to create intentional social changes, the editors of Behavioral and Brain Science appended 25 essays of open peer commentary, both supportive and opposing, to the original article. “Science should be an important agent of change, and it is,” Wilson, Hayes, Biglan, and Embry write.15 But, they argue that what science has been largely unable to accomplish is an understanding how to change human behavior and culture. The authors write, “our ability to change our behavioral and cultural practices lags far behind our ability to manipulate the physical environment. No examples of scientifically guided social change can compare to putting a man on the moon.”16 The question Wilson and his colleagues propose to answer (in the positive) is whether or not methods developed to grow bacteria, remove synthetic particles from ground water, or manipulate nano-sized particles be reformulated to convince people to exercise more, lessen their impact on the globe, change their diets, reduce violent behavior, or take their medications more regularly. Wilson, Hayes, Biglan, and Embry locate themselves within evolutionary theory, arguing that an intentional science must emerge from evolutionary theory since evolution, according to the authors, “is the study of how organisms change in relation to their environments” and evolutionary theory can “help us understand why some changes we desire, which count as adaptations in the evolutionary sense of the word, can turn out to be bad for long-term human welfare.”17 Yet, while evolution is often considered an observable and objective force, intentional science would manage and direct evolutionary processes. “Left unmanaged,” they write, “evolutionary processes often take us where we would prefer not to go. The only solution to this problem is to become wise managers of evolutionary processes.”18

 Wilson et al., 395.  Wilsonet al., 395. 17  Wilsonet al., 396. 18  Wilson et al., 396. 15 16

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An Intentional Humanities? The vision for an intentional science has direct concern for humanists and other human-focused disciplines. Citing cognitive behavior therapy, mindfulness-based therapies, and relational frame theory as examples of recent evolutionary-consistent and evidence-based therapies for achieving personal change, the authors acknowledge “an enormous amount of integration must occur” among the natural and human sciences before such an ambitious project could be realistically initiated.19 Human scientists may find Wilson’s offer precarious and the more human-focused scholars writing peer commentary claimed that much of the proposal is a naïve recasting of social Darwinism. In their response to “Evolving the future,” Paul Smaldino and Timothy Waring for example claim that social scientists (and we can include Humanists) “have no wish to be colonized by a ‘universal Darwinism.’”20 Humanities scholars, write Smaldino and Waring, have a long tradition of their own perspectives, theories, and explanations for human action, many of which are more complicated, nuanced, and written in direct contradiction to and with great suspicion toward Darwinism. Philosopher Shotra Sarkar cites social Darwinism, eugenics, and involuntary sterilization laws as only a few of the gifts a socially minded evolution has provided humanity.21 Sarkar argues that any discussion of intentional change using evolutionary principles must answer the questions (1) “What kind of future should we want?” and (2) “Who makes this decision and how?”22 Sarkar rightly recommends greater deliberation about what such change  Wilsonet al., 396.  Smaldino, Paul & Waring, Timothy. 2014. Let the social sciences evolve. Behavioral and Brain Sciences 37: 437. 21  For other “gifts” of modern science, see Rabinow, 2003. Rabinow writes, “We should never forget that what is nostalgically seen today as the golden age of science—the one before capitalism supposedly despoiled the life sciences—was the age of the Cold War. Today it seems implausible to maintain any longer that accumulating knowledge per se automatically leads to beneficial results, or, given its fragmentation, furthers our general self-understanding” (103). Yet, Rabinow is not ready to polemically denounce all of science as immoral. “Nor can we—and this is where Weber helps us avoid the fatuous denunciatory cant so widespread today—equivocally maintain that the opposite is the case, that is that science is malign and darkens our self-understanding” (103). 22  Sarkar, Sahotra. 2014. The inevitability of normative analysis. Behavioral and Brain Sciences 37: 436. 19 20

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would accomplish: “Instead of advocating intervention based on evolutionary reasoning, I wish to suggest that the appropriate lesson to draw from evolutionary analysis is that more effort be directed toward analyzing and resolving normative issues before we seriously consider intervention as an admissible policy option.”23 Similarly philosopher Muhammad Ali Khalidi argues human behavior is usually best explained in hindsight.24 Cognitive scientists have had limited success predicting human behavior, a claim also raised by psychologist Kenneth John Aitken who notes the “surprisingly poor” rates of prediction across populations resulting from evidence-based practice methodologies using large-scale datasets. Development is often “serendipitous” Aitken writes, and intentional influences are more accurately read and interpreted after the fact.25 An astute reader of “Evolving the future” and its commentary would recognize here a remaking and a certain, if unacknowledged, revisiting of the very same arguments accompanying those that gave rise to the humanist prohibition against intention (the intentional fallacy). Here, Khalidi’s critique is worth noting in full, Not only is the prediction of human behavior not feasible when one restricts oneself only to citing environmental variables: even if one posits internal cognitive states, these states do not always enable one to predict behavior. The unreliability of prediction when it comes to complex natural systems whether meteorological systems, biological systems, or human societies, means that it is risky to intervene to produce certain desirable outcomes.26

Thus, for Khalidi, “Given the precariousness of predicting the effect of social interventions, the moral hazards of such attempts at social engineering loom especially large.” Attempts to become “wise managers” of human behavior, Khalidi writes, “are unlikely to be welcome in general,  Sarkar, 36.  Khalidi, Muhammad Ali. 2014. The perils of a science of intentional change. Behavioral and Brain Sciences 37: 427–428 (427). 25  Aitken, Kenneth. 2014. Could Bertrand Russell’s barber have bitten his own teeth? A problem of logic and definitions. Behavioral and Brain Sciences 37: 416–417 (146). 26  Khalidi, 428. 23 24

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and are likely to backfire.”27 These are claims Wilson, Hayes, Biglan, and Embry readily acknowledge before they summarily dismiss. They write, “The study of evolution in relation to human affairs has a long and tortuous history that led many to abandon and even oppose the enterprise altogether…Evolution became a pariah concept to avoid as a conceptual foundation for the study of human behavior and culture for most of the twentieth century.”28 Here, the epistemological and rhetorical split over intention becomes apparent and problematic. While the humanists argue that intentional social change is precarious and ill-fated, writers from engineering, clinical disciplines, and psychology acknowledge such problematics but quickly move on to propose complimentary, more elaborate, corrective, and alternative ways to advance the very same intentional science.

Near Futility? The Reply As would be expected, in their reply to the peer commentary Wilson, Hayes, Biglan, and Embry do the same. “Ethics is a foremost consideration for any change effort,” they write. But they side-step the crucial issues Sarkar and Khalidi raise by arguing that ethical considerations for a change effort based on evolution are no different from any other change issue. Thus, change fails because people have incomplete information, because of group politics and individual self-interest, because people disagree on the ends (what is moral). Wilson, Hayes, Biglan, and Embry characterize these as largely technical problems, problems of transparency and accountability, not fundamental or epistemological. “We think it is important to be as explicit as possible about one’s facts, one’s values, and how they are combined to lead to a practical course of action, so that every component of the process can be examined and challenged if necessary” they write.29 The issue is not whether or not people should  Khalidi, 428.  Khalidi, 428. 29  Wilson, D.S., S. Hayes, A. Biglan, and D. Embry. 2014. Authors’ response: Collaborating on evolving the future. Behavioral and Brain Sciences 37: 438–448. 27 28

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intervene to create social change. That decision has already been made and is taken-for-granted. And as a consequence, it becomes a decision that creates a stalemate for the humanities in relation to an intentional science. Recognizing the near futility in engaging the humanities in their project, Wilson, Hayes, Biglan, and Embry ironically (and cleverly) cite their antagonists’ own constructions by claiming that evolution is actually nothing more than a biological process of social constructionism. “Within the human behavioral sciences and humanities, the disciplines that most appreciate social constructivism also tend to be most avoidant of evolution; yet, turned another way, social constructivists are making needed points about the importance of symbolic evolution.”30 Wilson and his colleagues raise a good question, how do humanists reconcile constructivist discourse and agnosticism toward intention? Aunger and Curtis raise a similar question in their response, noting that public health efforts have successfully used non-cognitive, emotional, and structural approaches to create behavioral change. Describing projects that utilize narrative, emotion, and deliberate environmental manipulations (pavement and landscaping) Aunger and Curtis argue that such approaches, emerging from narrative, design, and other human disciplines, have had greater success changing human behavior than those based in cognitive science and logical persuasion. In what seems to anticipate the social constructivist question, Peter LaFreniere writes that rather than seeing the organism as product of the environment, the environment is more typically created by the behavior of the organisms. “It is often the behavior of the organism that actively creates the environmental conditions under which morphological traits are selected.”31 LaFreniere notes that this evolutionary pattern is especially true in humans. Similarly, Michael O’Brien, citing Levins and Lewontin’s Dialectical Biologist, writes, “the organism influences its own

 Wilson, et al., 415.  LaFreniere, Peter. 2014. Evolving the future by creating and adapting to novel environments. Behavioral and Brain Sciences 37: 429–430 (430). 30 31

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evolution, by being both the object of natural selection and the creator of the conditions of that selection.”32 Embedded in the criticism Wilson and his colleagues have for the humanities is the humanist’s denial of an historical, empowered, constructive agency that formed modern rationality. Echoing Wittgenstein, Wilson accuses humanists of scaling the cathedral and then throwing away the ladder. Yet, Wilson et al. appear more nostalgic than overtly antagonistic toward the humanities. As noted above, they call for “an enormous amount of integration” among disciplines elaborating that “an integration that must be a two-way street, involving not only contributions of evolutionary theory to the human-related disciplines but also the reverse.”33 In other words, Wilson and his colleagues are approaching the humanities seeking a self-conscious and intentional discourse—a discourse that they believe echoes historical humanistic forms—that deliberately attempted to change health, culture, and behavior through narrative, architecture, design, and aesthetics.

 O’Brien, Michael. 2014. Niche construction is an important component of a science of intentional change. Behavioral and Brian Sciences 38: 432–433 (432). See: Levins, Richard and Richard Lewontin. 1985. The Dialectical Biologist Cambridge MA: Harvard University Press, 106. O’Brien’s constructivist claim is remarkably similar to the theory of discourse proposed by Lilie Chouliaraki and Norman Fairclough (1999) who write about the dual constitution of forms through discourse structures. They write, “It is an important characteristic of the economic, social and cultural changes of late modernity that they exist as discourses as well as processes that are taking place outside discourse, and that the processes that are taking place outside discourse are substantively shaped by these discourses (emphasis in original).” Chouliaraki, Lilie and Norman Fairclough. 1999. Discourse in late modernity: Rethinking critical discourse analysis. Edinburgh: Edinburgh University Press, 4. Further, describing systemic functional linguistics, they write, “The functional conceptualisation of language in SFL includes the claim that three major types of process are always simultaneously going on in language: the construction of reality, the enactment and negotiation of social relations and identities, and the construction of text” (48). Thus in the same way that texts simultaneously reflect and construct meaning the subject of evolution is both the agent and the recipient of both self and environmental change. 33  Wilson et al., 396. Of course, experience has proven to most humanists that a close eye on institutional budgets and tenure lines is prudent and necessary when a scientist or engineer talks about integration. 32

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 hanging Frames: From Science C to Urban Planning At this point, I turn away from the alchemic discourses of nano-­ manipulations and intentional sciences and toward related historical discourses of urban planning, specifically those associated with the rational socialization of urban space. I do this as a way to examine a previous, potentially mirroring, discourse I suspect has relevance for the new manipulative sciences of nano and micro tech and ultimately for the new intentional science. My effort in juxtaposing these parallel discourses, intentions, and practices ultimately leads to a question that continues to bother and motivate this study of emergent technology and intentional design: Whether science and technology’s embrace of these new intimate and intentional technologies constitutes modernity’s rational response to the failure of the humanities as a productive, proactive instrument for positive social change. In writing about a transition from classical to modern rationality in France, Rabinow argues that the “problem that social thinkers, reformers, architects, engineers, and emperors posed for themselves was one of bringing both norms and forms into a common frame that would produce a healthy, efficient, and productive social order.”34 In other words, new patterns of life, migrations from rural areas to cities, industrialization, transportation needs, and a new era of democracy demanded spaces that could accommodate educational, corporate, collaborative, and ­disciplinary norms. These norms required the architect to create new types, hospitals, public meeting halls, train stations, roads, which would blend and integrate new norms and forms. As Rabinow writes, “resuscitated cities must become perfect instruments, adapted to all of life’s needs.”35 These “perfect instruments” were rhetorically positioned as deliberate, intentional agents able to solve what were considered “unmitigated problems” especially sickness, hygiene, disease control, and economic development. “Planning,” Rabinow writes, “was the first principle of social  Rabinow, 1995, 11.  Rabinow, 1995. 276.

34 35

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hygiene; prevention was the most valuable of cures.”36 According to Herbert Lyauty, head of the protectorate in Morocco from 1912–1925, “common goals of health, vitality, justice, and beauty could only be actualized through a social hierarchy guided by an elite.”37 For Lyauty, these social goals could no longer be actualized through familiar classical methods—a transformation of inner lives, attempting to moralize a population through religion, asserting ethical superiority. Instead, social goals would be accomplished through purely technical operations and qualifications. In this way, the activities of planning shift from planning a city to managing social affairs including the technocratic details for the forms and events of life.38 Rabinow calls this emerging technocratic control of social life “middling modernism.” Importantly, its effect resided not on virtue, ethos, or morality, but instead, separated “social effect from the moral character of those running society.”39 Ultimately, this transition to rational modernity would be complete when, for example, a population’s “norms of health” as a function of measurement and instrumentation became the way to evaluate and judge health—as opposed to individual accounts, testimonies, religious beliefs, or folk myths.40 Importantly, the architects of these systems could put into place deliberate systems—sewers, clean water, segregated areas to control contagion—to achieve norms of health just as Wilson and his colleagues propose intentional science-based interventions to achieve individual and group changes for education, treating addiction, reducing pollution, or changing behaviors known to cause long-term health problems. Early attempts to introduce and legitimize spatial manipulations, at either the nano or the urban scale, presented their publics and benefactors with promises to cure disease, reduce crime, eliminate poverty, improve transportation, or create abundant renewable energy. Whether or not such claims are genuine, they are rhetorically motivating and  Rabinow,1995, 268.  Cited by Rabinow, 1995, 283. 38  Rabinow, 1995, 343. 39  Rabinow, 1995, 124. 40  Rabinow, 1995, 345. 36 37

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provide public legitimacy and political opportunity for this work. More simply, offering a promise, which the research aspires to fulfill, has become a generic component of scientific and engineering discourses. Planning and creating infrastructures to eliminate diseases, create efficient transportation routes, or reduce infant mortality can be technical. But articulating intentions beyond immediate problem solving, as Wilson and his colleagues appear to request, requires definitional and evaluative work that was historically left to morality, the church, or social hierarchies. Technologies can measure and administrate ad infinitum, yet, such middling could be seen to be occurring in a relative vacuum left by the discrediting of usual guide posts, of evaluative standards for what constitutes conditions necessitating change and those that become intentional outcomes.

Intention and Design in Academic Writing Early in this project, two graduate students, Jialiang Dong and Zheng Song, and I examined motivation statements in original research articles from twelve academic journals spread across science, engineering, business, and the humanities. We hypothesized that the extent to which authors would make explicit their motivation for a research project would differ among the disciplines and this degree of difference could be related to how much a particular discipline valued, or found legitimate, explicit statements of motivation. We read and characterized 305 articles from 12 journals (2010–2011) and documented whether or not the article explicitly stated a motivation for the research and textually where in the report that statement occurred.41

 Journals examined included: International Journal of Economics and Finance, International Journal of Operations & Production Management, Journal of Medical and Biological Engineering, Cell, Academy of Marketing Studies Journal, Journal of Environmental Engineering, Journal of American History, Chinese Studies in History, Cognitive Psychology, Early American Literature, Philosophy & Rhetoric, Journal of Religion & Society. Journals were selected randomly from a larger disciplinary list. 41

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Conceptually, the study conflated the concepts “intention” and “motivation,” positioning motive statements as forward-looking intentions. Following Anscombe, an intention can be a motive but not all motives are necessarily intentions. She writes, “I call a motive forward-looking if is an intention. For example, to say that someone did something for fear of … often comes to the same as saying he did so lest … or in order that … should not happen.” The research motive-statement fulfills Anscombe’s criteria as a statement of intent because it answers the question “why?” by being a description about “a future state of affairs.” Thus, the research is being conducted in order to bring a future state of affairs into being.42 For example, writing about the relationship between arm abduction, chest wall movement, and breathing, Chen, Liing, Lin, and Lu conclude the introduction to their study by writing, “The aim of the current study was to quantify the immediate effects of AASBM [arm abduction synchronized with breathing movement] on the three-dimensional (3D) motion of the chest wall activities of selective inspiratory muscles in healthy subjects during maximal inspiration.” Answering Anscombe’s “why?” they offer, “because chest wall motion is highly correlated with to lung volume, maintaining proper chest wall expansion capacity is vital.”43 Thus, the future state intended by the research is a quantifiable 3D AASBM model that will help people to breathe. Similarly, introducing their work on the interdependent relationships between environmental and genetic factors for congenital scoliosis (CS) in Cell, Sparrow et al. state, “Here we present evidence for a genetic etiology for CS and identify deleterious mutations in HES7 and MESP2 in individuals with CS from two unrelated families.” They continue and offer “why?”: “Our results have broad implications and may provide a mechanism for the genesis of a wide range of sporadic human congenital

 See Anscombe, 20–21. See also, Stoutland, Frederick. 2011. Introduction: Anscombe’s Intention in context. In Essays on Anscombe’s Intention ed. Anton Ford, Jennifer Hornsby, and Frederick Stoutland. Cambridge, MA, Harvard University Press. 43  Chen, Sheng-Chang, Liing Rong-Jiuan, Lin Kwan-Hwa, and Lu Tung-Wu. 2012. Immediate effects of arm abduction synchronized with breathing movement on the chest wall kinematics in healthy adults. Journal of Medical and Biological Engineering 32: 309–312, 309. 42

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defects through gene-environment interactions.”44 Nagati and Rebolledo, in the International Journal of Operations and Production Management, begin their article about transferring knowledge from smaller business partners and larger firms by stating, “we attempt to answer the following question: how does a supplier’s relative absorptive capacity affect knowledge transfer and its performance within the framework of customer-­ supplier relationships?”45 They study this question (“why?”) because it is difficult for large organizations to internally generate sufficient knowledge to maintain competitive advantages and one way in which firms have constructed greater knowledge capacity is through their customer-­ supplier relationships. These examples show not only explicit reasons for pursuing the research but they offer contextual statements suggesting “why” or to what intended end the research was being undertaken. Bundling the disciplinary motivation with a contextual reason (“why?”) produced what we considered the intention of the research study. We found that applied disciplines (business, engineering, psychology, economics) were explicit and formal when stating the intention for a research project. The intention could also be typically understood and contextualized by readers in other disciplines. In these articles, the intention was consistently articulated in the abstract or introduction and typically involved a tangible objective. Scientific journals had explicit statements about the intention of their research. However, authors also relied on significant a priori knowledge to appreciate the motivation and contextualize their projects within larger research questions. As such, readers from other disciplines would be less able to appreciate the study’s intention (Anscombe’s “why?”). The humanities articles had fewer explicit claims to intention and no formal requirements for locating these claims. When humanities articles  Sparrow, Duncan, Gavin Chapman, Allanceson Smith, Muhammad Mattar, Joelene Major, Victoria O’Reilly, Yumiko Saga, Elaine Zackai, John Dormans, Benjamin Alman, Lesley McGregor, Ryoichiro Kageyama, Kenro Kusumi, and Sally Dunwoodie. 2012. A mechanism for gene-­ environment interaction in the etiology of congenital scoliosis. Cell 149: 295–306, 296. 45  Nagati, Haithem and Claudia Rebolledo. 2012. The role of relative absorptive capacity in improving suppliers’ operational performance. International Journal of Operations & Production Management 32: 611–630, 611–612. 44

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did state the author’s motivation for undertaking the study, these statements did not occur in any specific section or location and were frequently spread across an article rather than located in a specific formal location. After studying these articles, we speculated that humanities authors were more likely to infer a motivation for their work and an audience sufficiently steeped within the discipline would recognize the future state the study was proposing (“why?”) and using a priori knowledge could anticipate why the motivation was important and relevant for the larger discipline. For example, writing about formation of creative metaphors in Philosophy and Rhetoric, Thomas Frentz offers a theory for understanding how creative metaphor is formed and a summary of the argument. As motivation, Frentz offers several questions, For example, are metaphors figurative deviations from more literal language use or is all language metaphorical at base? Or again, are metaphors exclusively linguistic devices or do they originate as more interior thought processes? Are metaphors ever capable of generating "new" knowledge or do they reconfigure the old? And finally, do some metaphors transcend cultural and ideological boundaries or are they all trapped within the tenor of their times?46

Frentz uses examples from Lakoff and Johnson, David Schön, and Wolfgang Pauli to demonstrate the utility of metaphor and in his conclusion writes that he hopes he has “produced some provocative ideas about the psychology of metaphor.”47 What future state Frentz would like to see emerge from this study may be implicitly apparent for scholars of linguistics, rhetoric, and related studies who might intuit multiple intentions (rhetorical, disciplinary, personal, epistemological) for the study. Scott Stroud, also writing in Philosophy and Rhetoric, offers a more explicit intention for his work; however, the intention is diffusely constructed across the article and requires considerable insider disciplinary knowledge. Stroud positions pragmatic criticism as an alternative  Frentz, Thomas. 2011. “Creative metaphors, synchronicity, and quantum physics.” Philosophy and Rhetoric 44: 101–128, 101–102. 47  Frentz, 126. 46

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rhetorical stance from more traditional critical forms arguing that “the problem with many theories of criticism is that they instantiate an extreme separation of the activities of life from the activities of criticism.”48 Stroud’s pragmatic criticism constructs a situational response to problems one finds locally in day-to-day activities. His intervention is a rhetorical practice available and deployed by “all humans at some point, not just professional critics via the written word.”49 Stroud may be splitting hairs, but he is more explicit about his intentions for this study: Critical rhetoric is “not incorrect,” he writes, “just not fully useful in accounting for the ways we use or could use criticism.”50 His intention seems to be to propose a more democratic positioning of the practices of criticism. His future state is announced in the conclusion, “the implied critic is one who has cultivated habits of attention and reflection such that he or she revels in the activities of life but also enjoys asking difficult and abstract questions when the practices of the present seem to call for such inquiry.”51 Certainly, as we have seen with nanotechnology, urban planning, and in the articles studied in this project, disciplines with a more applied focus could be expected to formalize explicit and generalizable intentions. Such disciplines often self-identify as “problem solving” and have built that proactive construct within much of their disciplinary forms. At the same time, it is not unexpected that disciplines with an historical skepticism toward intention would devalue explicit statements about authorial intent. Rhetorically, not only was intentionality formally divergent here; but, the work enacted across these articles and by extension by these disciplines was also fundamentally different. Technical articles seemed designed to objectively describe or compare a physical finding, discovery, or process and through the process of reporting, simplify and clarify the topic. The outcomes of these reports were tangible and readers were instructed primarily how to “do” the activity: to quantify a model for chest rise, identify environmentally sensitive gene mutations, or recognize if a business supplier could help members of a partnering firm  Stroud, Scott. 2011. John Dewey and the question of artful criticism. Philosophy and Rhetoric 44: 27–51, 38. 49  Stroud, 39. 50  Stroud, 41, emphasis in original. 51  Stroud, 48. 48

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generate knowledge. The humanities texts were more definitional and defining, valuing knowing and thinking above action. The humanities reports primarily instructed readers how to “think” about a concept, problem, or long-standing disciplinary topic (metaphor, criticism). For example, though Stroud concludes by defining a pragmatic criticism and offering new ways to think about the practice of criticism, the article does not instruct in how one might go about doing the activity of pragmatic rhetorical criticism.52

 onclusion: Interrogating Good Intentions C Yet Missing the Target Early writers in urban design and nanotechnology situated their work as intentionally pursuing solutions for extending health, reducing disease contagion, and improving public hygiene as motivations for the rationalization of urban/nano space. However, others, usually from a humanities or human-focused perspective, have extended and complicated this analysis, especially in an American context, to argue that these motivations quickly mutated into market-based initiatives in which such space planning and urban design became extensions of private economic interests. In his history “Intentionality and Urbanism in Los Angeles,” Michael Dear delineates a continuum in design intentionality which was instantiated by colonial, religious spiritual imperatives of LA’s Spanish Conquistadors and then reformed by the early colonial government to replicate Spanish colonial designs and city planning principles. Like Rabinow, Dear argues that a “distinctly modernist urban planning in LA” became evident in the combination of entrepreneurism and state capitalism in urban design. This period was marked by “excessive local boosterism,” “massive public infrastructure investment,” and what Dear calls “a fundamental split” between the spiritual and the material—in which

 These conclusions are similar to those reached by J.R. Martin in his comparison of scientific and historical research writing (discussed previously in Chap. 2). See Martin, p. 266. 52

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idealized planning was discounted and divorced from “localized processes of capitalist urbanization.”53 In events replicated across American urban design, this split subordinated land use planning to what Dear calls “the exigencies of local capital.” Here, promoters of private capital mobilized a discourse that down-played claims of intentionality and human motivation and emphasized common sense, “self-evident matters,” and technical means.54 In this marriage of American capitalism and technology, the apex came with the mass availability of the automobile creating what Dear calls, “an unstoppable impetus to the decentering imperative” and the “signature landscape of modernist Los Angeles—a flat totalization, uniting a fragmented mosaic of polarized neighborhoods segregated by race, ethnicity, gender, and class.”55 In this nexus of technology and capitalism we can transition back to nanotechnology and the urbanization of molecular space. Nanotech’s encounter with urban design enacts a more than metaphorical relation: Early motivations for nanotechnology were premised on equivalent goals as urban design: equipment for improving health and sanitation, prosperity, and social order; technologies for altering the materials and conditions of human life. In this way, nanotechnology operates as a deeply and necessarily urban project. Similarly, Richard Smalley and Robert Curl’s notation of their discovery of C60 as “buckyballs” also aligns nanotech with urban architectures, here the geodesic dome invented by utopian architect, engineer, and urban planner Buckminster Fuller. Like America’s history with urban planning, the contemporary anthropology of nano-­ micro technologies documents a transition from what could be considered spiritual pursuits to rational and commercial technologies. From stated designs, intentions, and blueprints to objectivist practices that deign association with political motivation, deliberate planning, or social prescriptions—yet have highly relevant and significant implications for social norms and forms. Like the land use planners in LA who claimed no  Dear, Michael. 1996. “In the city, time becomes visible: Intentionality and urbanism in Los Angeles, 1781–1991.” In The City: Los Angeles and Urban Theory at the End of the Twentieth Century, ed. Allen J. Scott and Edward W. Soja. Berkeley: University of California Press, 97. 54  Taylor, Nigel. 1998. Urban Planning Theory Since 1945. London: Sage. 55  Dear, 97. 53

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particular ideology or driving motivation beyond their own stated principles of good planning, today’s nanotechnologists claim a self-evident social consensus, operate according to their own determination of public interest, and what they alone have determined are current Good Manufacturing Processes (cGMP). Whereas what we can call emergent technologies promised their social networks solutions to disease, contagion, public hygiene, energy supplies, and food and nutritional shortages, their trajectory was quickly subsumed by government and then private capital. By the year 2000, the US government had spent over $10 billion on nanotechnology research. Yet, in a good year, only 3% of that budget had been targeted at investigating the environmental, health, and safety aspects of nanotechnology. And of that amount, most experts agree that most of that research has not even addressed its intended subject. In the same way that the utopia promised by the automobile led to massive public/private economic partnerships, a relationship that Dear writes was “consonant with the ambitions of developers and residents alike,” the scanning tunneling microscope, and the atomic force microscope paved the way for the similar commercial receipt of massive public spending and infrastructure.56 It is equally striking to recognize the way common critiques of urban planning have re-emerged as complaints about the management of emergent technologies. Dear presents a 1956 report by a Los Angeles transportation consulting firm that remarked, “LA was still without a comprehensive master plan despite the mandate given by a 1941 city charter revision. The report also highlighted problems of inadequate staffing, an absence of background research, excessive bureaucracy, and a lack of coordination between different levels of government.”57 A 2006 report by the National Research Council on America’s National Nanotechnology Initiative provided an equivalent assessment of the American nanotechnology research infrastructure, writing the US government does not have sufficient data or management structure to assess “any analysis of the economic impact of the NNI or activity such as

56 57

 Dear, 92.  Dear, 95.

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technology transfer.”58 The report called for a smaller, more dedicated group to set priorities and assess outcomes for nanotechnology investments and a more coordinated effort among government programs and departments. The report also called for better structures to ensure appropriate accountability within the National Nanotechnology Initiative and more accountable oversight of the initiative. Equally troubling is the critique of unintended consequences often leveled at urban planners. Thus, critics cite the “real ruin” of the Bronx district in New York City caused by the construction of the Cross Bronx Expressway, others have written about the atrophy of civic will that resulted from suburban relocation and the fragmentation of the urban city. And, noticeably, the litany of urban problems created by the automobile and the transportation infrastructures created to accommodate what was seen as an unstoppable and ultimately freeing technology. Similarly, the field of nanotechnology has been uninterested in accommodating the potential environmental, social, or legal consequences of their work and the US government has been equally uninterested in anticipating the unintended consequences of its investments. As Washington Post reporter Rick Weiss wrote about the National Research Council report, “If federal officials business leaders and others do not devise a plan to fill the gaps in their knowledge of nanotech safety, the field’s great promise could evaporate in a cloud of public mistrust.”59 Remarkably, the concern here is not public safety so much as the prolongation of research funding for the nanotechnology sector. Lastly, we turn to the issue of public involvement, consultation, and the impact of these disparate design practices on citizenship and democracy—ultimately a citizen’s ability to understand and determine the way their tax dollars are being spent. Urban design has a long history of mixed public consultation and involvement in building projects. As Carr has argued, “over 30 years of criticisms have been levied that planning as a discipline often fails to meaningfully broaden the democratic scope of  Committee to review the National Nanotechnology Initiative. National Materials Advisory Board. 2006. A matter of size: Triennial review of the national nanotechnology initiative. Washington, DC: National Academies Press, 9. 59  Weiss, Rick. 2006. “Nanotechnology risks unknown. Washington Post, Sept. 26. http://www. washingtonpost.com/wp-dyn/content/article/2006/09/25/AR2006092501138.html 58

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city government and enables politicians and planners to manipulate planning outcomes.”60 How the public would and should participate in the design of urban spaces has never been settled and continues to remain unclear and disputed largely on a project-by-project basis.61 Similarly, little significant effort has gone into consulting or even informing the public about new technologies (at least in America). Public opinion surveys report that only 40% of Americans even recognize the term “nanotechnology” and fewer have an opinion about the science.62 The latest count puts close to 1814 nano-derived or nano-utilization consumer products on the market (including cosmetics, sunscreens, textiles, and washing machines) from 622 companies in 32 countries.63 Yet, there remains no requirement to label products that contain active nanoparticles or that use nanotechnology’s unique properties. Much like home buyers who have no input on recreation facilities, transportation routes, or the availability of walkways in their neighborhood, consumers are now expected to unknowingly expose themselves to nanoparticles even though the environmental and health risks of these particles remain unknown or unsettled. Yet, like the human-facing critiques appended to “Evolving the future” little of this critique has had much influence or traction within technical disciplines. Despite what seem to be persuasive, compelling arguments  Carr, John. 2012. Public input/elite privilege: The use of participatory planning to reinforce urban geographies of power in Seattle. Urban Geography 33: 420–441, DOI: 10.2747/0272-3638.33.3.420. 61  Taylor writes that the field of urban planning has long “equivocated” between views that the public should have direct involvement in deciding planning policy and the view that planners themselves are best left to decide what is best for a particular community (87). 62  Waldron, Anna M., Douglas Spencer, and Carl A. Batt. 2006. The current state of public understanding of nanotechnology. Journal of Nanoparticle Research 8: 569–575. DOI: 10.1007/ s11051-006-9112-7. For specific examples from food industry, see Vandermoere, Frederic, Sandrine Blanchemanche, Andrea Bieberstein, Stephan Marette, and Jutta Roosen. 2011. The public understanding of nanotechnology in the food domain: The hidden role of views on science, technology, and nature. Public Understanding of Science 20: 195–206. Retzbach, Andrea, Joachim Marschall, Marion Rahnke, Lukas Otto, Michaela Maier. 2011. Public understanding of science and the perception of nanotechnology: The roles of interest in science, methodological knowledge, epistemological beliefs, and beliefs about science. Journal of Nanoparticle Research 13/12: 6231–6244. 63  Vance, Marina E., Todd Kuiken, Eric, Vejerano, Sean, McGinnis, Michael F. Hochella Jr., David Rejeski, and Matthew S. Hull. 2015. Nanotechnology in the real world: Redeveloping the nanomaterial consumer products inventory. Beilstein Journal of Nanotechnology 6:1769–1780. 60

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for caution, oversight, explanation, public input, or even simple notification, the disciplines appear to largely miss each other. How might we account for the ways these technologies are antagonistic to human participation and meaning making? What can our experience with manipulative technologies at the macro and micro levels tell us about intention and our ability to interface with, participate in, or even direct an intentional science? Witold Rybczynki’s critique of modern suburbia could be extended to modern science. Rybczynki writes: The contemporary suburb appears to be driven wholly by market forces and its development is not tempered as the first villa parks were, by any intellectual ideal, except perhaps that of individual freedom. Some kind of considered architectural response to the ways the majority of Americans want to live might be a good thing. I say "might" because the intervention of design professionals has not always had a salutary effect on the built environment.64

Yet, critiquing modern scientists for not following or constructing an intellectual ideal misses the mark and perhaps the point. While this chapter has emphasized the use of intention as a rhetorical form in scientific practice and the suppression of such a discourse in humanist work, at this point, this critique of intention becomes exactly opposite. While the sciences use explicit intentional discourses to retroactively justify their work, their practices as modern scientists have been established to exactly excise such motivations (meanings) from their disciplines. At the same time, while humanists deny an explicit intention, their work is overwhelmed with intentional discourses toward meaning. For science, intention anticipates and deploys technique whereas for humanists, intention solicits meaning. Two very different discourses deploying very different objectives. Two sections from Rabinow’s Anthropos Today are particularly relevant here. First, Rabinow revisits Max Weber’s essay “Science as a vocation” in order to mark a changing of the guard from Enlightenment thinking  Rybczynski, Witold. 1992. Looking Around: A Journey through Architecture. New York: Penguin, 105. 64

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about classical concepts to modern processes and technology.65 Weber’s essay, which was initially delivered as a lecture to German university students in Munich, provides a remarkable pivot in the ethos of scientific work. As Rabinow documents, Weber’s portrait of a changing science, from science as art (and by extension a way to understand nature) to science as technical practice, provides an early and perhaps a best description of science fundamentally breaking away from the Enlightenment. Weber importantly disassociates scientific practices from artistic endeavors, “scientific work is chained to the course of progress” Weber remarks, and unlike the arts, this new science is not designed to last or make any historical impact or legacy. “Science is designed to be surpassed” Weber explains: In science, each of us knows that what he has accomplished will be antiquated in ten, twenty, fifty years. That is the fate to which science is subjected; it is the very meaning of scientific work, to which it is devoted in a quite specific sense, as compared with other spheres of culture for which in general the same holds.66

Since every scientific discovery, technique, and explanation raises new questions that other scientists must replicate, validate, or challenge, science “asks to be ‘surpassed’ and outdated.”67 As a consequence, this new science is not interested in promoting a universal man, in seeing nature as a way to understand (or reject) God, in knowledge as a means for personal edification, universalizing truth, or linking rational thought to moral rightness, concepts promoted by Enlightenment thinkers. In effect, this new science, in Weber’s terms, is not interested in meaning at all. To require modern science to strive toward an intellectual ideal would be to impose Enlightenment thinking onto a practice that no longer derives value or motivation from such an enterprise. Even an answer to Sarkar’s  Rabinow, 2003, 96–102.  Weber, Max. 1946. Science as a vocation. In From Max Weber: Essays in Sociology ed. and trans H.H. Gerth and C. Wright Mills. New York: Oxford University Press, 129–156. (137–138 emphasis in original). Originally published as Weber, M. 1922. Wissenschaft als Beruf. In.Gesammelte Aufsaetze zur Wissenschaftslehre. Tübingen, 524–55. 67  Weber, 137–138. emphasis in original. 65 66

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questions of Wilson’s intentional science, “(1) What kind of future should we want?” and (2) “Who makes this decision and how?” seems largely out-of-scope.68 Weber, working from Tolstoy remarks, “Science is meaningless because it gives no answer to our question, the only question important for us: What shall we do and how shall we live?”69 These are the wrong questions to the wrong people. Since science does not intend to promote meaning. Modern science is neither interested in nor capable of answering such questions (or at least not capable of answering them with any complexity or rigor).70 Rabinow extends this argument to contemporary science, writing that, “today at least the natural sciences are untroubled by their loss of meaning because they are largely unaware of this state of affairs.” Rabinow continues: In fact, they are prospering financially and institutionally as never before. If there are deep conflicts of meaning adjacent to the life sciences—and there are, for example creationism versus evolution, playing God, and so forth—their existence has not altered or significantly influenced the forms and practices of modern biology one iota. Such discussions have been successfully cordoned off into a realm of “religion,” “ethics,” and “culture.”71  Sarkar, 436. While Wilson and his colleagues show great passion for the process and technical feat of intentionally intervening in social systems, apart from fairly obvious sentiments (“selling tobacco to minors is wrong”) and lessons learned from small-scale projects, they seem largely agnostic about why and to what ends such intervention would take. Wilson et al. acknowledge this ambivalence noting that the ultimate goals of interventions would be the result of technical processes of experimentation and variation and selection processes. See, Wilson et al., 446. Their approach is entirely consistent with Weber’s description of science even to the extent that they suggest using technical studies in epidemiology, public health, prevention science, neuroscience, and epigenetics to discern the end-point of their interventions. See, 446. 69  Weber, 143. 70  Rabinow’s point here is well taken, “Weber’s claim does not mean that many natural scientists do not have beliefs and opinions concerning the impact of their work; frequently they do. They often characterize such topics under the rubric of ‘consequences’ or ‘implications.’ Natural scientists, however, have neither the legitimate authority nor the scholarly capacity to defend their beliefs and opinions as truth claims with the same kind of discipline and rigor that their own disciplinary claims demand” (Rabinow, 2011, 182). A prestigious biologist, Rabinow remarks, will have his opinions about religion or ethics published only because he is a prestigious biologist, not because the opinions are particularly rigorous or helpful. Rabinow predicts that such remarks would probably not even find an audience in the humanities and social sciences literatures. 71  Rabinow, 2011. 183. 68

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This is not to say that modern scientists do not offer humanitarian ideals and progressive intentions as justification for laboratory practice, or that various commissions and centers do not produce bioethics reports, policy papers, and seminars.72 As we have seen with nanotechnology, there is a formal rhetoric to introducing a new science that links these practices to disease and health, energy, transportation, and perhaps more recently remediating the consequences of previous generations of science (pollution, chemical infiltration, extinction and depletions of native species, redressing public works projects). Yet, it would be a mistake to claim that any robust social theory or intellectual ideal drives these pursuits. It would also be a mistake to think that the obvious and superficial claims that a technology is being pursued specifically to address the most recent disease, weather crisis, natural catastrophe, asteroid, traffic jam, or computer problem that rises to the level of the New York Times or the Wall Street Journal are nothing more than retroactive justifications and smart marketing and grant writing. “Science contributes to the technology of controlling life by calculating external objects as well as man’s activities” Weber argued.73 This is neither a criticism nor a critique. To borrow from Rabinow, this is a state of affairs that is exactly as it should be.74 As a consequence, without a guiding sense of meaning, science-as-­ technique can be quickly turned into capitalist commodity. On the other hand, humanist practice, while striving for meaning, has both positioned its target and its value chronologically anterior to modern scientific problems and does not have a discourse commensurable to the technical intent espoused by their scientific colleagues. In requiring science to espouse meaning, or alternatively, critiquing scientific practice for the meanings it appears to be generating, humanists are exactly doing their job. Unfortunately, this is a job that has little salience for scientific intention.

 Rabinow, 2011, 183.  Weber, 150. 74  Rabinow, 2011. 183. 72 73

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In his essay “What is Enlightenment” Michel Foucault remarked that it is “dangerous” and “historically inaccurate” to confuse or conflate humanism and the Enlightenment.75 Humanism, he notes, is a targeted intervention that has appeared and reappeared at various moments in history as a corrective against particular structural forms and practices.76 As a consequence, he remarks, “we must escape from the historical and moral confusionism that mixes the theme of humanism with the question of the Enlightenment.”77 Humanism as an intervention provides a useful corrective at this point and a way to differentiate intention to think, which appears as the preponderant form of contemporary humanism, to intention to do, which would introduce a novel arrangement among contemporary humanist discourses. This brings us, in conclusion, to the second theme I would like to borrow from Rabinow’s Anthropos. Using Hans Blumenberg’s The Legitimacy of the modern age, as a sort of rhetorical foil, Rabinow asks why contemporary critiques of science and by extension so many “practitioners of modern reason” have resulted in so many failures. Recognizing our own education in survey courses, Norton anthologies, and the humanist requirement for historical precedence and citation, we can see that humanist disciplines are in many ways historical facing. In Rabinow’s terms, modern philosophy accepted as its inheritance and its challenge the great questions of history. Thus, even when working on contemporary issues, theories and critiques necessarily slide into questions about the nature of history, the definition of justice, the nature of being, the quest for identity, the nature of truth, the nature of communication. Such questions came to define modern humanism and continue to frame its interactions with and critiques of science and scientific practice. As a  Foucault, Michel. 1984. “What is Enlightenment?” In The Foucault Reader, ed. Paul Rabinow New York: Pantheon, 32–50, 43–44. 76  Foucault writes, “It is a set of themes that have reappeared on several occasions over time in European societies; these themes always tied to value judgments have obviously varied greatly in their content as well as in the values they have preserved” (1984, 44). Foucault notes that humanism has alternately risen as a critique against and as a component of Christianity, science, Marxism, existentialism, personalism, and other historical social and intellectual movements. 77  Foucault, 1984, 45. 75

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consequence, Rabinow suggests, humanists have inherited and brought to work, “the wrong tools for the wrong job.”78 Despite having extraordinarily different problems and sophisticated, complex means for addressing them, we continue to be, in Blumenburg’s words, preoccupied with “an attempt to answer a medieval question with the means available to a post medieval age.”79 “Perpetually futile and ever-renewed efforts” writes Rabinow.80 The United States currently spends over $200 billion on prescription medications each year, yet patients’ lack of adherence to medications results in 125,000 deaths every year, it is responsible for 10–25% of hospital and nursing home admissions, and has resulted in new strains of antibiotic resistant bacteria. Approximately 3.8 billion prescriptions are written each year but over 50% are never filled. The top reasons why patients do not take their medications include poor physician communication, patient misunderstanding and education, patient retaliation against an unpopular physician, patient finances, and a lack of social support for disease management. These are not scientific or technical problems nor are they problems that will be readily or ethically solved through intentional technologies. People’s unwillingness to take the COVID-19 vaccine had nothing to do with the scientific validity of the vaccine. This was clearly a problem with a humanities and not a scientific solution. Yet, in this failure of modern reason to adequately address actual issues of the day, the social intentionality of new technologies appears as an alternative method for reconstructing human infrastructures and social networks. Thus, in nanotechnology, microbiology, genetics, and proteomics we have fully technologized and unseen solutions to problems that continue to evade the humanities. As such, debates about, aesthetics, morality, virtue, history, ethics, or identity have had little effect on controlling the spread of infections, reducing behavior-­related morbidity and mortality, reducing youth incarceration rates, eliminating  Rabinow, 2003, 28–29.  Rabinow, 2003, 29. 80  Rabinow, 2003, 29. 78 79

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nosocomial infections, understanding the reasons for medical mistakes, reducing opioid dependence, or understanding why patients refuse or forget to take their medications. Here, we can agree with Wilson, these are problems with human behavior that perhaps humanists need to address. 81 Like early urban design discourses, the emergence of new manipulative technologies has claimed affinity with such perpetual human problems. Yet, without a clear and explicit (intentional) human direction these new sciences seem vulnerable to fragmentation by private commercial interest. Humanists need to engage this new aggregation of technology, science, capitalism, and humanitarianism with new equipment, new forms, and our own new aggregations. Such work may not have the dramatic promises of grand theories and large questions. These new aggregations may need to side-step the heroic and protective stance associated with the promises of the Enlightenment: the pursuit of character and virtue born from reason, an understanding of a universal nature, the value of universal and transparent knowledge (we do not need to know the mechanics of the subway to use it, notes Weber), the morality of complete freedom. Instead this new work will need to engage social and technical problems through new and provisional forms of granularity and intentionality. In “What is Enlightenment?” Foucault writes of an “experimental” attitude, work done “at the limit of ourselves” that “puts itself to the test of reality, of contemporary reality, both to grasp the point where change is possible and desirable, and to determine the precise form this change should take.”82 Without embracing their emphasis on evolution, Foucault’s proposed project is remarkably similar to that outlined by Wilson, Hayes, Biglan, and Embry. He argues that such a project would require us to move away from “projects that claim to be global or radical” and instead, examine those “specific transformations” that have led to the sorts of changes we would hope to achieve: “relations in authority,  Chesanow, Neil. 2014. Why are so many patients noncompliant? Medscape. http://www.medscape.com/viewarticle/818850_7 82  Foucault,1984, 46. 81

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relations between the sexes, the ways we perceive insanity or illness” and to these we could add: sexuality and gender, addiction and recovery, knowledge and pretense, governing and tyranny.83 Foucault concludes by ­proposing a means of practice, one that would “have their practical coherence in the care brought to the process of putting historico-critical reflection to the test of concrete practices.”84 How such practices might engage as a critique of intention will be the subject of the next chapter.

83 84

 Foucault, 1984, 46–47.  Foucault, 1984, 50.

5 System: Medicine, Intention, and Terministic Screens

The longest tradition in interpreting organizations is one that sees organizing efforts as intentional attempts by rational actors to manage practices within a collectivity. – March, Schulz, & Zhou (March, James, Martin Schultz, and Xueguang Zhou. 2000. The Dynamics of Rules: Change in Written Organizational Codes. Stanford, CA: Stanford University Press, 11)

Kenneth Burke rarely used the word “intention” and yet the problematics of intention seep throughout his Dramatistic screen. His direct articulation of intention, located in his short analysis of Pascal’s (1656) seventh Provincial Letter, is thoroughly rhetorical and could be read as overly strategic and retrospective. Intentions, he proposes, are socially approved purposes assigned to an act: “Then having done what we wanted to do” he writes, “we can assign a purpose to our act, selecting some intention socially approved.” He continues, “And we can ask that the act be considered as a means for carrying out this avowed intention.”1  Burke, Kenneth. 1950. A Rhetoric of Motives. Berkeley: University of California Press, 156. Italics in original. 1

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Burke advances the concept of “directed intention” directly from Pascal’s letter. However, the term subsequently becomes equipment for his concept of terministic screens which frames this chapter’s examination of systems and intention.2 In what follows, we trace how intention is interpolated within the systems of American healthcare. I use “interpolation” here to hedge the anthropomorphism of assigning intentions to a system. Systems are not human agents and yet systems produce, they align human action in ways that result in consequential results. Systems are human designs and over time agents create rules, policies, practices, and bureaucracies that align (in functional and dysfunctional ways) to produce results. By examining the multilayered, complex, and contradictory actions that aggregate within the provision of healthcare, this chapter’s experiment uses intention as a heuristic device to ask why a particular activity becomes prominent within a system and what those activities can tell us about that system. What we find are ways non-aligned incentives can cleverly use (direct intention) the terministic screen of medicine for their own financial purposes. This is not a repudiation of medicine, but a concern that the better intentions of the profession are being eclipsed by what Bitzer might call contrived exigency and spurious situations. The effect here has been detrimental to patients, clinicians, public health, and to the system itself. This chapter admittedly leans heavily on critique rather than action. But, recalling Martin’s insistence that “deconstructive and constructive activity are both required” in textual studies, my intention in this chapter is to experiment with using intention as a deconstructive device prior to noting more constructive activities in subsequent chapters.3 Additionally, this chapter uses intention as a self-reflexive heuristic to examine own my activities (constructive) in (para)medicine. Reviewing Burke’s reformulation of intention provides an instructive case in how such an encounter can configure an understanding of both intention and practice. Pascal’s letter concerns arguments, means, advanced by the Jesuits to justify acts like theft, simony, and even murder. By “taking off their intention from the sin itself, and fixing it on the  Kenneth Burke.1966. Language as Symbolic Action. Berkeley: University of California Press, 44–62.  Martin, 6.

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advantage to be gained” an injurious act is made right.4 When prompted that this scheme would allow anyone to “do any thing without exception” Pascal’s writer is informed that the line is drawn at “the formal intention of sinning, for the sake of sinning.” In the revealing passage Burke cites, Pascal quotes the Jesuit, “We exert indeed, the utmost of our power to dissuade men from doing what is forbidden; but when we cannot prevent the action, we at least aim to purify the intention, making amends for the vice of means by the purity of the ends.”5 While murder is a sin, proactively killing an enemy to protect one’s honor becomes permissible under the discursive scheme. While dueling is considered a sin, “A person may also kill an enemy secretly, and when this can be done, so as to get clear out of the affair, it is far better than fighting a duel.”6 Pascal’s skewering of religious hypocrisy is telling and amusing but Burke has a more contemporary purpose in his retelling. At the end of his analysis, he advances the concept of “directing the intention” toward his own political context, writing, “In the sphere of international relations, the politicians of one nation may seek to build and subsidize a mighty economic and military alliance against another nation, while ‘directing the intention’ toward peace.”7 A little over a decade later, Burke advanced the concept of “terministic screens” as a form of linguistic (mis)direction: “Here the kind of deflection I have in mind concerns simply the fact that any nomenclature necessarily directs the attention into some channels rather than others.”8 His essay on terministic screens begins with an immediate intertextual referent to “directing the attention” and a reiteration of Pascal’s satire. But whereas Pascal’s Jesuits were concerned with directing the intention, Burke’s terminstic screens, he writes, direct the attention. He describes a series of photographs he once viewed. The photos were different pictures of the same objects. Each picture, taken with a different color filter,  Pascal, Blaise. 1816. Provincial Letters Containing an Exposure of the Reasoning and Morals of the Jesuits. Trans by S. Hamilton. London: Gale and Fenner, 96. 5  Pascal, 97. 6  Pascal, 101. 7  Burke, 1950, 158. 8  Burke, 1950, 45. That the essay initially appeared in the Proceedings of the American Catholic Philosophical Association suggests an ironic intention deployed by Burke. 4

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­ ortrayed the object as a different form. Burke moves on from here to p demonstrate that terms produced by different ideological systems result in systematic ways for filtering concepts into unique and separate references. “We must use terministic screens,” Burke writes, “since we can’t say anything without the use of terms.”9 But this does not mean that meaning is necessarily relative. For Burke, the paradox of relativism is resolved in the difference between motion and action. A thing moves, Burke writes, while a person acts. “The slashing of the waves against the beach, or the endless cycle of births and deaths in biologic organisms would be examples of sheer motion,” Burke explains. “Yet we, the typically symbol-­ using animal, cannot relate to one another sheerly as things in motion.”10 Motion itself is amoral and without agency. But human action can be attributed to motive and as such should not be reduced to relativism. When Burke places “action” as an identifying term for the confluence of morality and motion, “more-than-motion,” he simultaneously evokes the terms motive and motivation.11 In this aggregation he returns to intention without explicitly marking the term. This intention is less strategic, retroactive, and deployable than Pascal’s deflection and is more complex than the simple will of an agent. “More-than-motion” posits intention as a confluence generated by motive, act, and morality. While intention in this new formation retains its trace as an ethical concept, moving from Pascal to Burke, from direction to screen, intention is remediated from retroactive explanation (interpretation) to production (action).

Act: Intention in Medicine—Retraining In the Introduction, I wrote that actively managing a disease is an intentional effort to operationalize desire. Yet, disease complicates planning and execution because of the way perception and activity are restlessly oriented to short-term goals and daily functioning. Rushing to get to work we forget to take our medication. We stop taking antibiotics when  Burke, 1950, 50.  Burke, 1950, 53. 11  Burke, Kenneth. 1969. A Grammar of Motives, Berkeley: University of California Press, 65. 9

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a wound seems more-or-less healed. Meetings and family obligations interfere with exercise. Healthy meals are time consuming and expensive. Two years out from my anti-diagnosis, I enrolled in an evening paramedic program offered by a local community college in Massachusetts. I had been volunteering as a basic EMT for about eight years and had several reasons, both personal and professional, for wanting to attain higher certification. Despite living in Worcester, MA, I continued to volunteer as an EMT in upstate New York. As a more experienced (read: “old”) EMT in rural New York, it was not unusual for me to go to calls assisted only by a non-medical driver. When working with higher acuity patients, trauma patients, or patients in cardiac arrest, I had a general idea of what was required, but I was not trained or credentialed to provide more complex care. Medical school was not financially or professionally feasible and yet I was looking for a more formalized medical education than my self-education had provided. I thought that the additional education and ultimate certification as a paramedic could extend and improve my university teaching and better enable me to build productive collaborations with students and researchers in the life sciences. 12 And, going back to school to gain an advanced credential was also part of this book’s larger project to investigate what an intentional humanities could mean. Recalling Paul Rabinow’s difficulty integrating his anthropological perspective within the SynBERC synthetic biology research center, I had also hoped that attaining clinical experience would evoke some recognition among my science colleagues that I was making an effort to meet them, if not half, perhaps somewhere around a third of way toward their own expertise. My own academic interests were also changing at the time, incrementally experimenting with the boundaries of the humanities and  While a basic EMT certification is usually obtained through a 4–6 month college course, a typical paramedic program can range from a 2-year associates degree to a 4-year bachelors degree. Programs require prerequisites in anatomy and physiology and require approximately 80 credit hours (for the associates degree). Requirements include courses in assessment, pharmacology, cardiology, trauma, ob/gyn, neonatology, and pediatrics; hospital rotations in ICU, Emergency Department, Anesthesiology (Surgery), Labor and Delivery, Emergency Mental Health; and an apprenticeship with a paramedic agency. While local protocols differ, paramedics can obtain IV access, administer between 15–20 different medications, conduct EKGs in the field, perform advanced airway management, and deliver cardiac electrical therapy. These are not advanced programs in science, research, or medicine I fully recognized. Yet, they provided sufficient grounding to access advanced medical literature, attend conferences and lectures, and become acutely aware of what I didn’t know. 12

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the sciences in my own efforts to see what was possible and desirable in re-creating new pedagogical and research forms and actions. As the Affordable Care Act rolled out across the United States, I began teaching a course titled “Writing about disease and public health” which was my university’s first healthcare policy course enacted as a junior year writing seminar. Subsequent pedagogical efforts included courses in writing pathology, healthcare analytics and quantitative literacy, and senior honors theses in epidemiology and public health. For the latter, writing students with a double major in the life sciences (writing and biology; writing and biomedical engineering) typically completed a year-long senior project studying a pathogen in the lab, creating a medical device, or examining how to remove a polluting chemical from ground water or soil. To complement these technical projects, my students would examine and create a science writing thesis about the diseases associated with these pathogens. For example, a student studying candida in the lab completed a writing project on sepsis or candidiasis infections. Students looking to remove 1–4 dioxane from ground water studied and wrote about kidney cancers. An engineering student working on respirators studied pulmonary diseases. Here was a model that challenged my emerging knowledge and my own department’s topical, thematic, and purposeful boundaries.

Agent I: Intentional Heroism While we would expect that more training in a field would correlate with better outcomes, the medical literature has recently, but repeatedly, shown that advanced prehospital care (ALS) has been associated with worse outcomes than basic care (BLS) mostly among cardiac arrest patients. Among patients suffering out-of-hospital cardiac arrest, urban ALS has been shown to have no association with survival rates to hospital discharge and may be associated with higher mortality.13 Prachi Sanghavi  See for example, Sanghavi, Prachi, Anupam. Jena, Joseph. Newhouse, and Alan. Zaslavsky. 2015. Outcomes after out-of-hospital cardiac arrest treated by Basic vs Advanced Life Support. JAMA Internal Medicine 175: 196–204. doi: https://doi.org/10.1001/jamainternmed.2014.5420. For discussion see Greene, Jan. 2016. Claims data study casts doubt on value of out-of-hospital advanced life support. Annals of Emergency Medicine 67: 11A-A14. https://doi.org/10.1016/j. annemergmed.2015.12.009 13

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and colleagues, in a retrospective statistical study of prehospital cardiac arrest encounters using Medicare billing data, found that not only were there “no meaningful differences on any observed measure between the BLS and ALS [treated patient] groups,” but that the BLS patient groups had a higher survival rate to hospital discharge, 30 days, and 90 days post-discharge. Patients who received ALS in the field had higher mortality in the first days after the heart attack. Among those patients who survived the cardiac arrest, ALS patients had higher percentages of poor neurological function than those who received BLS care. ALS has been associated with longer delays to hospital arrival. Other studies have shown little to no effect of the recommended prehospital ACLS drugs for cardiac arrest.14,15 This research has suggested that the ALS cohort had poorer outcomes because a good deal of the advanced interventions taught to treat cardiac arrest in the prehospital setting, skills  Cournoyer, Alexis, Éric Notebaert, Massimilano Iseppon, Sylive Cossette, Luc Londei-Leduc, Yoan Lamarche, Judy. Morris, Éric Piette, Raoul Daoust., Jean-Marc Chauny, Catalina Sokoloff, Yiorgos Cavayas, Jean Paquet, and André Denault. 2017. Prehospital advanced cardiac life support for out-of-hospital cardiac arrest: A cohort study. Academic Emergency Medicine 24: 1100–1109. DOI: https://doi.org/10.1111/acem.13246. The Ontario Prehospital Advanced Life Support Study Group report is cited as a benchmark study for ALS versus BLS in prehospital cardiac care: Stiell, Ian, George Wells, Brian Field, Daniel Spaite, Lisa Nesbitt, Valerie De Maio, Graham Nichol, Donna Cousineau, Josée Blackburn, Doug Munkley, Lorraine Luinstra-Toohey, Tony Campeau, Eugene Dagnone, and Marion Lyver. 2004. Advanced cardiac life support in out-of-­ hospital cardiac arrest. New England Journal of Medicine 351: 647–656. The Ontario study also found no incremental benefits from adding ALS to out of hospital cardiac emergencies. 15  On drug therapy, see: Lundin, Andreas, Therese. Djärv, Johan Engdahl, Jacob Hollenberg, Per Nordberg, Annika Ravn-Fischer, Mattias Ringh, Ssusanne Rysz, Leif Svensson, Jjohan Herlitz, and Peter Lundgren. 2016. Drug therapy in cardiac arrest: A review of the literature. European Heart Journal-Cardiovascular Pharmacotherapy 2: 54–75. DOI: https://doi.org/10.1093/ehjcvp/pvv047. On prehospital use of epinephrine see Shao, Huan and Chun-Sheng Li. 2017. Epinephrine in out-­ of-­hospital cardiac arrest: Helpful or harmful? Chinese Medical Journal 130: 2112–2116. DOI: https://doi.org/10.4103/0366-6999.213429. On prehospital intubation, see Lecky, Fiona, Daniele Bryden, Rod Little, Nam Tong, Chris Moulton and Cochrane Injuries Group. 2008. Emergency intubation for acutely ill and injured patients. Cochrane Database Syst Rev 16: CD001429: doi: https://doi.org/10.1002/14651858.CD001429.pub2. Hanif, M. Arslan, Amy Kaji, and James Newman. 2010. Advanced airway management does not improve outcome of out-of-hospital cardiac arrest. Academic Emergency Medicine 17(9): 926–31. Doi: https://doi. org/10.1111/j.1553-2712.2010.00829.x. Lecky et al. conclude that “The efficacy of emergency intubation as currently practiced has not been rigorously studied” and “In trauma and pediatric patients, the current evidence base provides no imperative to extend the practice of prehospital intubation in urban systems.” Hanif, Kaji, and Niemann write, “In this cohort, when compared to BVM ventilation, advanced airway methods were associated with decreased survival to hospital discharge among adult nontraumatic OOHCA [out of hospital cardiac arrest] patients.” 14

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like endotracheal intubation, epinephrine, vasopressin, and amiodarone administration have little if any empirical evidence of patient benefit. Sanghavi et al. argue that such procedures may actually take prehospital providers’ focus away from good quality CPR and rapid defibrillation (when indicated)—interventions that have been shown empirically to improve patient outcomes. The researchers also note that ALS providers appear to be delaying hospital transport, adding time to what could be definitive treatment for some patients.16 So, the question needs to be asked, why encourage and promote ALS care? What are the intentions associated with protocols that seem out of date (and based on little ­evidence) and training in procedures that not only may have little lifesaving value but take away focus from actions (like aspirin, CPR, and early defibrillation) that have a strong empirical basis. Now as a paramedic I also need to ask what are my intentions when providing prehospital care? Perhaps an easy way out is to question the validity of the research. In an editorial commentary accompanying the Sanghavi et al. study, Michael Callaham notes that the researcher’s methods could be questioned because they were unable to document the actual treatment provided to patients and whether the treatment was appropriate and conducted properly. Other critics have argued that such studies fail to grasp the complexities of the prehospital care system, that ALS patients simply could be sicker (the research is simply tautological), or that some services provide ALS interfaces with BLS transports who wait for ALS to the detriment of patient care.17 Jeremy Lacocque argues that the study could not measure compliance with accepted protocols, noting that a recent study documented that 86% of ALS crews failed to provide proper ALS treatments  Sanghavi et al., 201–202. On ALS delaying transport, see Stiell et al.  Shanghavi et al. argue that their model accounts and corrects for each of these possibilities. For example, on patient severity they write that they called 911 dispatchers in 45 state EMS agencies who reported that ALS is dispatched to any cardiac-related emergency. They write, “BLS would only be dispatched when ALS is unavailable, leaving no clear remaining mechanisms to explain why less severely ill patients would be preferentially dispatched” (203). On ALS intercepts with BLS ambulances, they write that they calculated the number of BLS cases that would need to be incorrectly attributed to ALS (BLS waiting for ALS resulted in poor patient outcome). This event “would have to occur in an implausibly high proportion of BLS cases to change the direction of our effect” (203). 16 17

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during cardiac arrest according to guidelines.18 While an interesting methodological argument, Lacocque’s data does not speak well to the added expense and training of ALS prehospital care. Despite their criticisms of these studies, both Lacocque and Callaham agree that Sanghavi et al.’s data largely confirms what other researchers have been concluding about the use of ALS in out of hospital cardiac arrest. Callhahm writes, “the likelihood that their [Sanghavi et al.’s] findings are true is strengthened by its consistency with a growing body of research demonstrating the ineffectiveness of many ALS therapies.”19 Callaham writes that ALS resuscitation techniques emerged in the 1960s from case reports and “small uncontrolled case series of asphyxiated healthy young dogs.” He argues that the medications used for cardiopulmonary resuscitation were introduced before 1962, when the U.S. Food and Drug Administration required demonstrations that a drug had efficacy for its intended use. “Research methodology was far less sophisticated” Callaham writes, “and few or none of these studies would be published in a major journal today.”20 The trend in EMS research, he argues, is that policies are made on “small, poorly controlled, and mostly positive” studies and then “larger more rigorous studies that follow are all negative.”21 Yet, very rarely does out of hospital practice change to account for these correctives. Perhaps the question is too narrow. ALS advocates argue that limiting these studies to cardiac arrest patients overlooks the cases when well-­ trained medics saved lives by giving diabetic patients intravenous sugar, treating allergies and respiratory distress, or recognizing early signs of sepsis, heart attack, or stroke. The debate here suffers as well from personal anecdotes. I vividly recall an 82-year-old patient at a nursing home whom the nurses claimed was suffering from COPD exasperation. Yet, after measuring the patient’s exhaled carbon dioxide levels, finger stick  Lacocque, Jeremy. 2015. A JAMA study adds fuel to the anti-ALS fire, but is the research credible? Emergency Physicians Monthly (4/1). http://epmonthly.com/article/back-to-basics/#REF. 19  Callaham, Michael. 2015. Evidence in support of a back-to-basics approach in out-of-hospital cardiopulmonary resuscitation versus “advanced” treatment. JAMA Internal Medicine 175: 205–206. 20  Callaham, 205. 21  Callaham, 205. 18

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blood sugar, and seeing a recent hospital discharge for pneumonia I could see that this was not COPD but appeared to be respiratory compensation for a metabolic acidosis (potential sepsis) and the repeated albuterol therapy administered by the nursing home potentially could be making the patient’s condition worse.22 Here was a complicated diagnosis that was unavailable to me as a BLS provider (score 1 for ALS). Other medics echo their own war stories, how recognizing ST elevations in a field EKG enabled rapid thrombolytic therapy in the emergency department that saved the patient’s life; how advanced airway management skills unplugged a blocked trachea in an unconscious chocking patient and restored breathing; how electrical pacing kept a patient’s heart beating until a cardiologist could reset a dysfunctional pacemaker. EMS loves its heroes and at $24 an hour the field offers very little other incentives to attract or keep its practitioners.23 Medicine in general, and not just EMS, loves to be heroic. Or, as Atul Gawande, writing in the New Yorker, puts it “we have a certain heroic expectation of how medicine works.”24 Noting that he himself was drawn to the heroic qualities of medicine, the opportunity “to be in charge and solve a dangerous problem,” Gawande recalls impressive developments in infectious disease, vaccines, surgery, and organ transplantation. “It was like discovering that water could put out fire,” he writes. And here the stories, our stories, continue: I recall being called to the apartment of a  On lactic acidosis and beta agonist therapy see: Liem, Edwin, Stephen Mnookin, and Michael Mahla. 2003. Albuterol-induced lactic acidosis. Anesthesiology 8: 505–506. Rodrigo, Gustavo and Rodrigo, Chaturaka. 2005. Elevated plasma lactate level associated with high dose inhaled albuterol therapy in acute severe asthma. Emergency Medical Journal 22: 404–408. DOI: https://doi. org/10.1136/emj.2003.012039. Lawrence Lewis, Ian Ferguson, Stacey House, Kristen Aubuchon, John Schneider, Kirk Johnson, and Kazuko Matsuda. 2014. Albuterol administration is commonly associated with increases in serum lactate in patients with asthma treated for acute exacerbation of asthma. Chest 145: 53–59. DOI: https://doi.org/10.1378/chest.13-0930. 23  Employment for EMTs and paramedics is expected to increase 15% between 2006–2026, a rate faster than the average of all US occupations (7%). Yet, median pay for the field has remained weak. Despite the considerable scope of practice and responsibilities, wages for prehospital providers have never been good. Median pay in 2016 for EMTs and paramedics was $15.71 per hour or about $32,670 a year. Of course, some agencies pay better, into $20–$25 per hour for paramedics, and most services offer payment differentials for working nights, weekends, and overtime. Yet, in many rural communities, it is still common for volunteers to provide prehospital emergency services. 24  Gawande, Atul. 2017. The heroism of incremental care. New Yorker, Jan 23. https://www.newyorker.com/magazine/2017/01/23/the-heroism-of-incremental-care 22

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middle-aged woman for a diabetic emergency. When we arrived there was only silence when we knocked on the unlocked door. Upon entering we found our patient lying unresponsive on the bed, barely breathing. Placing a bag-valve mask over her mouth and breathing for her, we started an IV and began running liquid sugar into her arm. Barely a minute later she began breathing on her own and within another minute she was awake and talking to us. Several years ago I watched the stage performance of a college student who, six months earlier, stopped breathing in the back of the ambulance after we found her intoxicated at a snow bank. As Gawande writes about his own stories of transformative, emergency life-saving procedures, “How can anyone not love that?” The stories of clinicians as heroes remain fundamental and productive to both medicine and storytelling. They are also fundamental to recruitment, retention, and why people dedicate their careers and their lives to healthcare. These stories have intention. In Burke’s words, they are “more than motion.” They are why we pursue ALS certification, why we go to extreme lengths to resuscitate patients, why we put in one more shift, one more call, and why and how physicians like Gawande become international ambassadors for medicine. As intentional actions, these stories deploy and conflate motive, act, and morality. They also explain why, even in the face of empirical data, we refuse to do less, why we want to give unproven medications in cardiac arrest, why it is nearly impossible to remove a procedure from a protocol and to leave a tool in the tool kit. Intention sets us up for a “bias for action” argues Robert Winchell, a professor of surgery at Weill Cornell Medicine, even when that action is not in the best interests of our patients.25

 Robert Winchell. 2019. Prehospital interventions that should not be done. Trauma and Critical Care Symposium. Harvard Medical School, Nov 11. Winchell, Professor of Surgery, Chief Division of Trauma, Burns, and Acute and Critical Care at Weill Cornell Medicine argued that pre-hospital care (like many medical specialties) suffers from a bias for action. The practice favors “aggressive and invasive intervention on minimal evidence” and rarely identifies negative outcomes related to interventions. Winchell persuasively argues that cricothyroidotomy and needle chest decompression “should not be done” in a prehospital setting. The procedures are very infrequent, difficult to teach, train for, and keep current, they have enormous risk, are difficult to preform, and are of minimal (if any) clinical benefit. Yet, they persist in most prehospital agency’s standing orders. 25

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 cene: The Intention of Unsustainable S and Dysfunctional Health Systems In the United States, through intentional efforts and unintended consequences, stories of medical heroism are being overshadowed by a health system in trouble and transition. This dysfunction became acutely apparent and avulsed during the COVID-19 pandemic. The problem is familiar and well known: Healthcare is costly, services are fragmented, and quality and access to care are uneven and unpredictable. Americans spend over $3 trillion on health care year after year, and most of that cost (75%) will be spent on managing chronic diseases like congestive heart failure, diabetes, chronic lung disease, and dementia.26 In 2009, America spent over $7960 per capita on health care, which was 50% more than second-­ place Switzerland and almost twice as much as Canada.27 Healthcare absorbed 17.6% of the U.S. gross domestic product in 2010 and yet, according to the World Health Organization, the United States ranked 6th (a tie with Cuba) behind Japan, Italy, Canada, France, Germany, and the United Kingdom in life expectancy; 4th in cancer mortality, 6th in cardiac mortality, and 10th in male and female obesity rates. Three-­ quarters of Americans aged 65 and older suffer from two or more chronic conditions, and 20% of these patients have five or more chronic conditions.28 In 2012, the United States spent $13.9 billion on the care and  Wennberg, John, Elliott Fisher, David Goodman, and Jonathan Skinner. 2008. Care of chronic illness in last Two years of life. Dartmouth Atlas of Health Care Analysis. http://www.dartmouthatlas. org/data/topic/ topic.aspx?cat=1. See also, Institute of Medicine of the National Academies. 2012. Living well with chronic illness: A call for public health action. http://www.nationalacademies.org/ hmd/~/media/Files/Report%20Files/2012/Living-Well-with-Chronic-Illness/livingwell_chronicillness_reportbrief.pdf. Accessed 9 July 2017. 27  Emanuel, Ezekiel. 2008. Healthcare, Guaranteed: A Simple, Secure Solution for America. New York: Public Affairs. See also, Klein, Ezra. 2021. High health-care costs: It’s all in the pricing. Washington Post, Feb 28, 4 http://www.washingtonpost.com/business/high-health-care-costs-its-all-in-the-­ pricing/2012/02/28/gIQAtbhimR_story.html 28  Anderson, Gerard. 2005. Medicare and chronic conditions. New England Journal of Medicine 353: 305–09. See also, Thorpe, Kenneth, and Philyaw, Meredith. 2012. The medicalization of chronic disease and costs. Annual Review of Public Health 33: 409–423. DOI.org/10.1146/ annurev-publhealth-031811-124652. Wu Shin-Yi and Amanda Green. 2000. Projection of Chronic Illness Prevalence and Cost Inflation. RAND Corporation, October. The National Association of States United for Aging and Disabilities has developed an online slide show presenting impact of chronic conditions on hospital utilization, healthcare costs, and patient quality of life at http:// www.nasuad.org/sites/nasuad/files/hcbs/files/191/9519/ChronicCareChartbook.pdf 26

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treatment of mental disorders in children and $8.3 billion on children with chronic obstructive pulmonary disease and asthma.29 In 2017, for the second year in a row, American life expectancy declined, largely due to opioid overdoses.30 Clinical heroism may be inspiring but it does not appear to be working. Early efforts to reform America’s health system have emphasized process engineering and information technology. These efforts have attempted to introduce or revise processes to increase system efficiencies, reduce utilization, avoid patient readmissions, and reduce overall system costs.31 For example, industrial engineers have modeled what they call optimized processes in areas as diverse as medication delivery, emergency department patient flow, and surgical department scheduling.32 At a more micro scale, statisticians and business intelligence experts have advocated new methods for acquiring, monitoring, and publishing comparative quality metrics within and between health systems in the hopes that by providing data transparency physicians might compete for better patient outcomes and patients might choose clinicians and healthcare facilities with better rankings and measures.33  Soni, Anita. 2015. Statistical brief #472: Top five most costly conditions among children, ages 0–17, 2012: Estimates for the U.S. civilian noninstitutionalized population. U.S. Department of Health & Human Services, Agency for Healthcare Research and Quality. 30  New York Times. 2017. Soring overdose deaths cut US life expectancy for 2nd year. New York Times, Dec 21. 31  Sharma, Gulshan, Yong-Fang Kuo, Jean Freeman, Dong Zhang, and James Goodwin. 2010. Outpatient follow-up visit and 30-day emergency department visit and readmission in patients hospitalized for chronic obstructive pulmonary disease. Archives of Internal Medicine 170:1664–70. Nutting, Paul, William Miller, Benjamin Crabtree, Carlos Roberto Jaen, Elizabeth Stewart, and Kurt Stange. 2009. Initial lessons from the first national demonstration project on practice transformation to a patient-centered medical home. The Annals of Family Medicine 7: 254–60. Denton, Brian, Murat Kurt, Nilay Shah, Sandra Bryant, and Steven Smith. 2009. Optimizing the start time of statin therapy for patients with diabetes. Medical Decision Making 29: 351–67. Hansen, Luke, Robert Young, Keiki Hinami, Alicia Leung, and Mark Williams. 2011. Interventions to reduce 30-day rehospitalization: A systematic review. Annals of Internal Medicine, 155: 520–28. 32  Chalice, Robert. 2007. Improving Healthcare Using Toyota Lean Production Methods. Milwaukee WI: ASQ Press. Grunden, Naida. 2008. The Pittsburgh Way to Efficient Healthcare. New York: Productivity Press. Kolker, Alexander. 2008. Process modeling of Emergency Department patient flow: Effect of patient length of stay on ED diversion. Journal of Medical Systems 32: 389–401. 33  Berger, Steven. 2005. The Power of Clinical and Financial Metrics: Achieving Success in your Hospital. ACHE Management Series. Chicago IL: Health Administration Press; Center for Medicare and Medicaid Services. 2012. CMS HER meaningful use overview, March. See also, Brownlee, Shannon. 2008. Overtreated: Why too much Medicine is Making us Sicker and Poorer. NY: Bloomsbury. 29

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Some of the greatest changes in healthcare are expected to result from the wide-scale adoption of data-intensive healthcare information technology systems. The electronic medical record (EMR), used by clinicians at the point-of-care, promises seamless processes: electronic registration and insurance verification, simple and efficient physician diagnosis and documentation, seamless “one click” ordering of labs and radiology exams, rapid electronic results and verification, instant health information and education emailed to the patient, electronic prescriptions sent to the closest pharmacy, and an electronic bill sent to (and electronic payment received from) the insurance company. An associated technology, electronic health records (EHR) aggregate and store patient data from the EMR’s multiple visits, sites, and events. Advocates argue that the EHR enables system-wide coordination of services and data, addressing the considerable fragmentation among primary care physicians, specialists, surgeons, and allied health providers. The EHR also enables retrospective research into cost, outcomes, and quality, enabling researchers and clinicians to discover the “whys” behind their numbers. In 2009, the federal government’s American Recovery and Reinvestment Act provided $19 billion in incentives for health systems to adopt electronic health record technologies, including EMRs. These incentives are aligned within provisions for what has been termed “meaningful use.” As an organization attains higher levels of “use” they can attain greater incentive payments. Yet, nearly a decade in, these approaches have been expensive but have yet to make any serious dent on healthcare expenditures. According to the Centers for Medicare and Medicaid Services, in 2016, national healthcare expenses grew 4.3% to $3.3 trillion, or $10,348 per American. That $10,348 (globally the greatest expense per capita) bought the United States a global ranking of 31st in life expectancy. In 2016, I was asked to make some sense of similar but less organized and less structured micro-scale data when a friend took over as the manager of a chronic care management program at a local hospital-owned clinic. For the past two years, the staff had been keeping a spreadsheet with granular data about their heart failure program. The program’s goal was to manage this patient population to avoid hospital readmissions. A readmission occurs when a patient who has been discharged from inpatient status at a hospital is admitted again to inpatient status. Most metrics follow 30-day readmissions but others track 60 and even 90 day readmits.

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Readmissions are considered adverse events and avoidable not only because they are expensive but because patients admitted to the hospital are more likely to get even sicker by contracting bloodstream infections, gastrointestinal illness, or pneumonia, especially if they receive a central line.34 In an effort to understand the current state and effectiveness of the program, and understanding my new career re-orientation, my friend asked me to examine the spreadsheet and “provide some feedback.” Some of the more immediate findings were not surprising, patients with shorter lengths of stay (2–3 days) and people over 70 years old were at greater risk for readmission. Patients who experienced one readmission were at greater risk for more. Sicker patients were more likely to have multiple readmissions.35  Magill, Shelly, Jonathan Edwards, Wendy Bamberg, Zintars Beldavs, Ghinwa Dumyati, Marion Kainer, Ruth Lynfield, Meghan Maloney, Laura McAllister-Hollod, Joelle Nadle, Susan Ray, Deborah Thompson, Lucy Wilson, and Scott Fridkin. Multistate point-prevalence survey of health care-associated infections. New England Journal of Medicine 370: 1198–1208. See also, Brownlee, 43–71. 35  Hospital readmissions have become a standard, if still controversial, measure of acute care quality. A readmission occurs if a patient who discharged from inpatient status returns to any hospital within 30 days and is admitted again to inpatient status. As of 2016, as part of their process improvement efforts, the Center for Medicare and Medicaid Services (CMS) calculates each hospital’s readmission rates for any diagnosis (“all cause”) and for five specific conditions: pneumonia, chronic obstructive pulmonary disease, heart failure, acute myocardial infarction—“heart attack”— and total joint replacement (hip, knee). Hospitals that have a three-year retrospective readmission rate higher than a risk-adjusted rate predicted by CMS are financially penalized. If a hospital has a lower rate than the expected, they receive a financial bonus. While a strong literature has argued, perhaps rightly, that the metric better evaluates post-discharge care coordination than inpatient care, the measure is now seen as standard way to evaluate quality of care. For criticisms for the measure, see Jha, Ashish. 2013. The 30-day readmission rate: Not a quality measure but an accountability measure. https://blogs.sph.harvard.edu/ashish-jha/2013/02/14/the-30-day-­ readmission-rate-not-a-quality-measure-but-an-accountability-measure/ Accessed 4 Jan 2022. The American College of Cardiology has published a critical editorial claiming that the 30-day readmission metric is an inappropriate way to measure quality of care for heart failure patients, writing that in adopting the measure, “policy trumps science.” The editorial is available on-line at http://www. acc.org/latest-in-cardiology/articles/2013/08/22/17/47/30-day-readmission-a-lousy-qualitymetric-­in-hf. Press et al. provide a compelling argument that readmissions do not measure the events or processes that lead to best patient outcomes. Press, Matthew, Dennis Scanlon, Andrew Ryan, Jingsan Zhu, Amol Navathe, Jessica Mittler, and Kevin Volpp. 2013. “Limits of readmission rates in measuring hospital quality suggests the need for added metrics.” Health Affairs 32: 1083–1091.This literature argues that readmissions are associated with post-hospital care and care coordination among specialists and primary care providers and are not reflective of the care that occurs within the inpatient setting. If anything, the measure appears to be a policy device to force hospitals to get involved in post-discharge care and primary care by establishing larger regional health systems. See Bradely, Elizabeth, Curry, Leslie, Horwitz, Leora, Heather Sipsma, Yongfei Wang, Mary Walsh, Don Goldmann, Neal White, Ileana Piña, and Harlan Krumholz. 2013. Hospital strategies associated with 30-day readmission rates for patients with heart failure. Circulation Cardiovascular Quality and Outcomes 6: 444–450. 34

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I should introduce some evaluative terminology here. A “LACE” score is a commonly used patient severity score that evaluates the likelihood that a patient could be readmitted or even die after being discharged from the hospital. The score aggregates the length of stay of the patient’s initial admission; the acuity of the admission, adding extra points if the patient is admitted through the Emergency Department; co-morbidities that accompany the primary diagnosis; and the number of emergency department visits the patient has had in the past 6 months. A score between 6 and 9 is considered “moderate risk” for readmission and a score greater than 10 is considered “high risk” for readmission. The good news was that we found that the LACE tool worked. Readmitted patients had higher LACE scores calculated during their initial hospital stay than non-readmitted patients. Nurses and social workers visited 63% of patients prior to discharge and 81% of patients with LACE scores higher than 10. We also found that patients who saw a primary care provider between 3 and 7 days after discharge were less likely to be readmitted—a finding that has been confirmed by the research literature on primary care follow-up appointments.36 The bad news was that even though the tools appeared to work, only 15% of patients who had a LACE score greater than 10 had a documented follow-up appointment with their PCP within a week of their initial discharge. While patients were visited before discharge, these visits  Faber, Brenton, Andrew Trapp, Christine Tang, and Renata Konrad, 2015. Examining the impact of regular physician visits on heart failure patients: A use case with electronic health data. Health Systems 30 October DOI: https://doi.org/10.1057/hs.2015.13. Brooke et al. found that early follow-­up with a PCP reduced readmissions (18% lower likelihood) after high-risk surgery (an open thoracic aortic aneurysm repair, TAA) but did not influence readmissions after lower risk surgeries (ventral hernia repair, VHR) though the rate for the lower risk VHR was already small (8.6%). Initial readmission rates were 36.6% for TAA repair which declined to 20.4% with follow-up, see, Brook, Benjamin, David Stone, Jack Cronenwett, Brian Nolan, Randall DeMartino, Todd MacKenzie, David Goodman, Philip Goodney. 2014. Early primary care provider follow-up and readmission after high-risk surgery. JAMA Surgery 149: 821–828. Early physician follow-up has also been shown to reduce readmissions among patients with psychiatric issues, see Kurdyak, Paul, Simone Natalie Vigod, Alice Newman, Vasily Giannakeas, Benoit Mulsant, Therese Stukel. 2018. Impact of physician follow-up on psychiatric readmission rates in a population-based sample of patients with schizophrenia. Psychiatric Services 69: 61–68. On patients with heart failure see, Hernandez, Adrian, Melissa Greiner, Gregg Fonarow, Bradley Hammill, Paul Heidenreich, Clyde Yancy, Eric Peterson, Lesley Curtis. 2010. Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. JAMA 303: 1716–1722. On patients with COPD admissions see, Sharma, Gulshan, et al. (note 331). 36

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had no effect on readmissions as 93% of readmitted patients had been visited prior to discharge. After discharge from the hospital, 30% of patients with a LACE score higher than 10 were never contacted. Perhaps the most interesting finding was that patients who were readmitted were 11% more likely to have a follow-up appointment after the readmission. In other words, only after patients experienced one or more readmission did it appear that interventions were put in place to mitigate further readmissions. Despite having the tools, research, and expertise proven to predict and potentially mitigate further hospital readmissions, the actions here reacted to crisis rather than intervening proactively to prevent potential complications.

 gent II: The Antihero—Intentional A Preventative Care Unlike the familiar heroic stories of medical discovery, diagnosis, and life-saving treatments, the stories recounted above are disturbing as they detail investments in prehospital education and care that might do more harm than good; extraordinary public and private spending on what amounts to middling and in some cases worsening healthcare outcomes; expensive and sophisticated electronic health systems that have had little positive impact; clinicians having but largely ignoring tools for reducing hospital readmissions and mitigating potential patient harm. What can such stories teach us about intention, not simply individual intention, as undoubtedly no clinician would incur an additional years and debt of schooling to provide worse patient outcomes and no nursing case manager would admit to actively encouraging patient readmissions. What these stories ask us to consider are systemic intentions, intentions oriented and incentivized by large and complex systems. Asked differently, what can intention teach us about a health care system that appears unable or unwillingly to proactively reach out to vulnerable patients in an effort to keep them healthy and away from expensive, extreme, and dangerous experiences? What can intention teach us about a system that incentivizes paramedics to go to heroic lengths to replenish

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depleted blood glucose in patients with diabetes and restore breathing in intoxicated college students but has no legal methods for those same paramedics to provide routine health check-ups or home visitations?37 My paramedic experience has also taken me to several free primary care clinics where I assist with patient assessments, phlebotomy and laboratory testing, patient education, stacking chairs, serving coffee and cookies, and doing dishes. Free clinics are operated across the country often in churches, schools, and other public buildings. According to the National Association of Free & Charitable Clinics, there are approximately 1200 free clinics in the United States. In 2016, these clinics saw 1.8 million individual patients through 6 million visits. Clinics provide medical, dental, and vision services including lab tests, chronic care management, immunizations, and general physical exams for school and work. One autumn evening I met a young woman at our clinic who came for diabetes testing for her parents, “it runs in the family” she noted as I found a vein and drew a tube of blood from her mother’s arm. The following week, the trio returned with their suspicions confirmed, both mom and dad had elevated HbA1c levels, a specific test that measures the average blood glucose levels over the past three months. The volunteering physician started the couple on insulin shots and glucose monitoring. They left with boxes of free insulin syringes and prescriptions, blood glucose testing kits, and instructions to keep a journal recording their blood sugar levels and report back their data the following week. We educated the family on how to draw up the insulin, properly inject themselves, and how to use their new blood testing kits. The following week the family returned with their log books and the physician incrementally adjusted  Several jurisdictions have experimented with “community paramedicine” in which paramedics with additional training make home calls to check in on patients with known health risks. Programs typically are affiliated with emergency departments that provide paramedics with lists of recently discharged patients who have agreed to receive follow-up care. Community paramedics provide assessments, assistance with medication and discharge instructions, in-home consultations and education, care for minor injuries and illnesses that do not require transport or hospital consultations, and immunizations such as flu and pneumonia shots. The programs can also facilitate communication among a patient’s care team. Obstacles to these programs include state medical regulations that restrict paramedics’ scope of practice to prehospital or transport care, no reimbursement model for home-based consultations, and jurisdictional issues among nurses, home health aides, and other employment groups that provide home-based assistance. 37

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their dosing. We discussed nutrition, diet, and exercise as ways to mediate the effects of the disease and they left with instructions to come back again the following week. This pattern repeated for several months, initially weekly, then every other week, and then once a month until the physician was comfortable with the family’s reported results. These experiences are far less adrenalin-­ charged than prehospital emergency care. But these patient encounters, repeated here week after week with hundreds of patients and multiple medical conditions, probably have more important and longer term benefits to our patients, to the community, and to the local health system than waiting for and heroically responding to a crisis. Not that acute and emergency care is not important. But a good deal of emergency care could be avoidable. The Centers for Medicare and Medicaid Services even have a designation ambulatory care-sensitive conditions which describe acute and chronic conditions that, in their words, “are potentially preventable given appropriate primary and preventive care.”38 The list includes common EMS complaints, angina, asthma, dehydration, influenza, pneumonia, and diabetes complications. In gross terms, primary care physicians are scored on the number of patients under their care who are admitted for one of 19 conditions (with exclusions). Physician groups who have higher hospital admissions for these conditions than a peer-group average receive a penalty (modifier) in their Medicare payments. Physician groups who outperform their peer group average receive a bonus in their Medicare payments. The ambulatory care-sensitive conditions program is part of the federal government’s decades-long attempt to move away from fee-for-service payments in American healthcare. As the name implies, fee-for-service ascribes payment for each activity provided to the patient. The more care provided to the patient, the higher the cost and the more payment  For full explanation of ambulatory-sensitive conditions, see the CMS description and list at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeedbackProgram/ Downloads/2014-ACSC-MIF.pdf. The US Department of Health and Human Services’ Agency of Healthcare Research and Quality has published a white paper describing the rationale and evidence for each preventions indicator. The guide is https://www.ahrq.gov/downloads/pub/ahrqqi/pqiguide.pdf 38

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(reimbursement) to the healthcare provider. Healthcare policymakers have argued that a system driven by payment-for-services inevitably results in unnecessary care, higher costs, and more expensive treatments as incentives all drive toward more care and more complex treatments. A less familiar, yet arguably more significant, component of the 2015 Affordable Care Act introduced alternative payment mechanisms that focused on episodes of care rather than individual encounters. Calling the approach “value-based purchasing” the proposals were designed to bundle episodes of care for heart failure, chronic obstructive pulmonary disease, heart attack, and hip and knee replacement surgery. Medicare would pay a set amount for the entire episode of care (typically 30 days post discharge). Any complications would need to be covered by the lump sum payment. Policymakers claimed that such bundled payments would necessitate high-­quality care, care coordination, and an emphasis on preventative care once a patient leaves the hospital as no further payments would be forthcoming within the 30-day window.39

 Value-based purchasing was incrementally phased into Medicare payments with hospital and health systems voluntarily participating with experimental heart failure and joint replacement programs. However, in 2017 then director of Health and Human Services Tom Price issued wide-­ ranging exemptions for physicians for merit-based programs. Price, an orthopedic surgeon, was highly critical of payment reform and advocated moving back to fee-for-service payment models. For coverage of Tom Price’s criticisms of value-based purchasing and efforts to reinstate fee for service see: Kilgore, Ed. 2017. Tom Price’s old-school approach at HHS is just what the doctors ordered. New York Magazine, 1 August, http://nymag.com/daily/intelligencer/2017/08/tom-price-­ at-hhs-is-just-what-the-doctors-ordered.html, Accessed 4 January 2022. Mershon, Erin. 2017. With Tom Price in charge, doctors are winning again in Washington. Stat, 1 August. https://www. statnews.com/2017/08/01/tom-price-doctors/. Accessed 4 January 2022. Japsen, Bruce. 2017. Why health insurers worry about Trump’s HHS pick, Tom Price. Forbes, Jan 4. https://www.forbes. com/sites/brucejapsen/2017/01/04/why-health-insurers-worry-about-trumps-hhs-pick-tom-­ price/#4e206db23583. Accessed 4 January, 2022. Price was forced to resign after spending government funds on charter and military flights for himself, his wife, and staffers. At the time, Politico reported $1 million in travel expenses between May and September 2017. Politico also reported other ethical concerns about Price including investments in health care companies while in the House of Representatives. See, Diamond, Dan, Rachana Pradhan and Adriel Bettelheim. 2017. Price resigns from HHS after facing fire for travel. Politico, Sept 29, updated Sept 30. https://www. politico.com/story/2017/09/29/price-has-resigned-as-health-and-human-services-secretary­243315. Accessed 4 January 2022. On general efforts to change the Affordable Care Act’s provisions for Value-Based Purchasing, see: Goodnough, Abby and Kate Zernike. 2017. Trump health agency challenges consensus on reducing costs. New York Times, Nov 12. 39

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 gency: Intentionally Designing an Effective A Health System Of course, simply stating that patients with pneumonia, asthma, or the flu should be treated in out-patient settings is easy. Assuming patient adherence, improved results from influenza and pneumonia vaccinations are (were once) plausible; but changing outcomes in stubborn chronic conditions such as heart failure and COPD becomes problematic. Yet, some programs have seen success, the 2013–2016 national readmissions rate (US) for Medicare patients with COPD was 19.8%, heart failure 21.6%, and pneumonia 16.9%.40 As Desai et al. reported, these numbers have declined since 2008 after CMS implemented readmissions penalties. In hospitals subjected to penalties, Medicare heart attack (MI) readmissions declined 27%, heart failure 23%, pneumonia 28%, and non-targeted readmissions declining 19%. These results were greater than declines in Medicare readmissions among non-participating hospitals (MI, 20%, HF, 10%, PN, 21%, NT, 14%,).41 As Desai et al. noted, readmissions rates declined faster for incentivized conditions. Among hospitals with no incentives to reduce readmissions, there were still reductions but the reductions were smaller than incentivized systems.42 Such results suggest that rhetorically, withholding payment from medical systems provides sufficient incentive to make large systemic changes. Barrett and colleagues found similar findings, documenting that from 2009–2013, all-cause readmissions among Medicare patients declined from 18.1% to 17.3%. However, readmissions among non-Medicare patients, patients with Medicaid and private insurance (no financial  Readmissions metrics cited from Center for Medicare and Medicaid, Hospital Compare. https:// www.medicare.gov/hospitalcompare/search.html? 41  Desai, Nihar, Joseph Ross, Ji Young Kwon, Jeph Herrin, Kumar Dharmarajan, Susannah Bernheim, Harlan Krumholz, and Leora Horwitz. 2016. Association between hospital penalty status under the hospital readmission reduction program and readmission rates for target and non-­ target conditions. Journal of the American Medical Association 316(24): 2647–2656. doi: https:// doi.org/10.1001/jama.2016.18533. See also, Wasfy Jason, Corwin Zigler, Christine Choirat, Yun Wang, Francesca Dominici, and Robert Yeh. 2017. Readmission rates after passage of the hospital readmissions reduction program: A pre-post analysis. Annals of Internal Medicine 166: 324–331. DOI: https://doi.org/10.7326/M16-0185. 42  Wasfy et al., 2648. 40

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incentives) did not change during this time and readmissions among patients without insurance (no financial incentives) increased by 8.9%.43 It is hard to argue that physicians, nurses, and case managers did not know that additional hospitalizations were not in a patient’s best interest, or that readmissions were risky only for Medicare patients and not for, say, 56 year old patients with heart failure but no insurance or Blue Cross Blue Shield. Yet, when a hospital system was not financially incentivized to enact such changes, changes did not happen. Writing in a Circulation editorial, Colleen McIlvennan, Zubin Eapen, and Larry Allen argue that financial penalties assessed against readmissions have been successful in changing systemic practices.44 “Before 2012, hospitals had little direct financial incentive to reduce readmissions” they write.45 That system, write McIlvennan et al., “entrenched silos of care, in which acute care hospitals were largely incentivized to get patients only well enough to leave the hospital.”46 As a result, proactive care coordination among specialists, transitional care, patient education, and preventative care was less emphasized. Penalizing excess readmissions may have placed greater emphasis on proactive actions and may have begun to reorient certain health systems from fee-for-service to a system focused on patient outcomes. McIlvennan et al. write that an outcomes-based system would be preferable as it focuses “what matters to patients, caregivers, payers, and society” including a focus on not just the patient’s primary medical diagnosis, “but also on a patient’s comorbid, psychological, social, and environmental conditions.”47  Barrett, Marguerite, Lauren Wier, Joanna Jiang, and Claudia Steiner. 2015. All-cause readmissions by payer and age, 2009–2013. Healthcare cost and Utilization Project, AHRQ. https://www. hcup-us.ahrq.gov/reports/statbriefs/sb199-Readmissions-Payer-Age.pdf. Accessed 4 January 2022. 44  McIlvennan, Colleen. Zubin Eapen, Larry Allen. 2015. Hospital readmissions reduction program. Circulation 131: 1796–1803. https://doi.org/10.1161/CIRCULATIONAHA.114.010270 45  McIlvennan et al., 1796. 46  McIlvennan et al., 1798. 47  McIlvennan et al., p, 1798–1799. At the same time, the authors note that while the program may be a good start, methodologically unless socioeconomic factors are built into the readmissions algorithm, the program disproportionately punishes hospitals that serve poorer and sicker populations. The authors also suggest that the 30-day window appears largely arbitrary and that penalties could be weighted against days from discharge such that a readmission occurring 2–3 days after discharge becomes more considerable than one occurring 29–31 days after discharge. 43

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While such methodological problems remain rhetorically consistent with using financial incentives to drive changes in healthcare practice, the exigence is problematic. Studies have shown a poor association between readmission and mortality, suggesting that improving readmission rates have had little to no effect on patient mortality.48 Other reports have claimed that the benefits seen in readmissions could be attributed to coding changes on admission or by administrators actively refusing to admit higher acuity patients by transferring them to larger academic teaching centers. Ibrahim, Dimick, Sihna, and colleagues found that hospitals participating in readmissions reduction programs increased coding the number of comorbidities on a patient’s initial admission by 38.98% (versus 19.6% for those not participating). Up-coding acuity in this way places hospitals within peer groups with a higher severity of illness thus improving their comparative readmission rates. Ibrahim and colleagues claimed that as much as 63% of the reduction in readmissions could be due to such coding changes. More troubling, a September 2017, US Government Accountability Office report claimed problems with clinical information metrics provided by Veterans Affairs Hospitals. The report claimed that the clinical documentation and subsequent metrics were inaccurately reporting patient information and clinical practices. A follow-up report by the New York Times claimed that hospitals had limited the number of highacuity patient admissions by transferring sicker patients to other hospitals, in an attempt to improve their quality metrics.49 Responding to the findings, the GAO report wrote, “As a result, VA does not have assurance that the quality measures it publicly reports on Hospital Compare and its own website accurately reflect the performance of its VAMCs and provide  Gorodeski et al. found an inverse relationship between readmission and heart failure: Gorodeski, Eiran, Randall Starling, and Eugene Blackstone. 2010. Are all readmissions bad readmissions? New England Journal of Medicine 363: 287–298. DOI: https://doi.org/10.1056/NEJMc1001882; Krumholz, H., Zhenqiu, L., Keenan et al. found no association among heart attack and pneumonia and a weak negative association for patient admitted for heart failure: Krumholz, Harlan, Zhenqiu Lin, Patricia Keenan, Jersey Chen, Joseph Ross, Elizabeth Drye, Susannah Bernheim, Yun Wang, Elizabeth Bradley, Lein Han, and Sharon-Lise Normand. 2013. Relationship between hospital readmission and mortality rate for patients hospitalized with acute myocardial infarction, heart failure, or pneumonia. Journal of American Medical Association 309: 587–593. 49  Philipps, Dave. 2018. At Veterans Hospital in Oregon, a push for better ratings put patients at risk, doctors say. New York Times, January 1. 48

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v­ eterans with the information they need to make informed choices about their care.”50 What to make of such quality programs like efforts to reduce readmissions? Are they intentionally designed interventions to remedy injurious situations or reactions to a conjured and contrived exigence? What their implementation and resulting actions have shown is that when incentivized, people can achieve a targeted goal but not necessarily an intended one. We can reduce the statistical count of patients readmitted within 30 days of their discharges but such an effort does not necessarily improve patient care, reduce cost, or improve population health. To borrow language from the book’s introduction, we are again confusing significance and meaning. Achieving a reduction in readmissions may be a significant (noticeable) achievement but it does not appear to be a meaningful one.

The Ratios I  ct/Agent/Purpose: The Patient, the Physician, A and Intention at Cross Purposes In her 1992 book, The Meaning of Illness, Kay Toombs articulates what she calls two “separate worlds” occupied by patients and physicians and the possibility of integrating these disparate spaces.51 Writing from the dual perspectives of both a philosopher and a person with multiple sclerosis, Toombs claims that our perspectives about disease and health are not so much ideological or theoretical but instead formed and grounded in everyday, immediate experience. In the introduction to her book, she writes, “In discussing my illness with physicians, it has often seemed to me that we have been somehow talking at cross purposes, discussing different things, never quite reaching one another.”52 Toombs is thoughtful  United States Government Accountability Office. 2017. “VA health care quality: VA should improve the information it publicly reports on the quality of care at its medical facilities.” September https://www.gao.gov/assets/690/687523.pdf. Accessed 4 January 2022. 51  Toombs, S Kay. (1992). The Meaning of Illness: A Phenomenological Account of the Different Perspectives of Physician and Patient. Dordrecht NL: Kluwer. 52  Toombs, xi. 50

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about these crossing discourses, noting that they do not emerge from “inattentiveness or insensitivity” but instead, “from a fundamental disagreement about the nature of illness” and a motivation “to attend to different aspects of the experience.”53 The physician, she writes, “is trained to perceive illness essentially as a collection of physical signs and symptoms which define a particular disease state.” Illness for the physician manifests apart from the patient and the patient’s experience but as a form unique to itself. As Toombs writes, “He or she thematizes the illness as being a particular case of ‘multiple sclerosis,’ ‘diabetes,’ ‘peptic ulcer,’ and so forth.”54 Here, the physician’s intention is to diagnose, to discover, and characterize disease. Toombs’ characterization here recalls Foucault’s description of the pathological fact as medicine modernized, “In order to know the truth of the pathological fact” he writes, “the doctor must abstract the patient.”55 The diagnosis must separate signs and symptoms that accompany the disease from what we would now call the patient’s normal baseline. Foucault writes, “Paradoxically, in relation to that which he is suffering from, the patient is only an external fact; the medical account must take him into account only to place him in parenthesis.”56 In this way, the patient is merely the bearer of the disease, “that through which the text can be read,” the “accident of his disease.”57 Paraphrasing her colleague Eric Cassell, Toombs writes, “On being presented with a sick person doctors do not attempt to find out what is the matter but, rather, attempt to make a diagnosis.”58 These are different forms and actions and understanding that physicians diagnose disease recognizes a specific professional intention. Patients may expect physicians not merely to recognize or plausibly discover disease but to treat and cure this object of discovery. Yet, from the physician’s perspective, once diagnosed, the game is up.  Toombs, xi, 11.  Toombs, 11. 55  Foucault, M. 1973. The Birth of the Clinic: An Archaeology of Medical Perception. Trans. A.M. Sheridan. New York: Vintage Books, 8. 56  Foucault, 1973, 8. 57  Foucault, 1973, 59. 58  Toombs, 12. Toombs’ citation is paraphrased from a letter she received from Eric Cassell. 53 54

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In Toombs’ account, the patient more-or-less delegates diagnosis and treatment to the physician while the patient experiences illness and disease as something that impedes day-to-day activities and experiences. The patient does not much care about the identity of the disease, but does care about how the disease influences experience. “One does not ‘see’ one’s own illness primarily as a disease process.” Toombs records, “Rather, one experiences it essentially in terms of its effects upon everyday life.”59 Such different perspectives are readily apparent for someone who moves between patient and physician experiences. As a prehospital care provider, I am called when a person’s symptoms reach the point when they interfere with the expectations and experiences of daily life. At the same time, after transferring care to the Emergency Department, I can appreciate the physician stating that room 10 is a classic case of right ventricular heart failure. This is not to argue that patients do not, or are unable to, perceive their disease or understand the biological mechanisms of their pathology. Toombs writes that a patient can come to understand chest pain as a heart attack and abdominal pain as gall bladder disease, but such explanatory work does not attach meaning to the episode in the same way a diagnosis has meaning for the physician.60 For the patient, the interpretation and assignment of meaning are primarily experiential and immediate. This meaning can also be influenced by gender, group dynamics, ethnicity, family health history, insurance status, and other human dynamics. A patient may recognize arthritic pain in her knee as something common to what her mother and grandmother also experienced but identifies and assigns meaning to the pain as a disease only when it becomes fully disruptive.61 Here, again, meaning, significance, and intention are entangled and oppositional. For the patient, a shingles diagnosis is significant but not meaningful while for the physician, debilitating pain is significant but outside of the diagnosis (shingles) not very ­meaningful. Each agent’s intention then works in apposition, in parallel tracks that rarely intersect.  Toombs, 11.  Toombs, 36–37. 61  Toombs, 38. Toombs creates a distinction between “suffered illness” and “disease.” Suffered illness, she writes, is “pre-reflective sensory experience” while for the patient, identifying a condition as a “disease,” requires reflection, learning, and a certain amount of objectivity and distance from the immediacy of the condition. 59 60

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For physicians, diagnosis is a biomedical activity intended to identify an objective pathophysiological fact. Toombs goes so far as to argue that, “it is concluded that patients’ complaints that do not correlate with demonstrated pathoanatomical and pathophysiological findings are not bona fide illnesses.”62 The diagnosis is a “theoretical abstraction which is distinct from, and not identical with, the patient’s experiencing.”63 A diagnosis has an objective, scientific meaning apart from the patient and the consequences the pathology may be inflicting on the patient. Here, as Foucault claimed, the patient is merely the host of the disease. Toombs and others correctly note that this distinction between patient and physician meaning has keen clinical relevance. While the physician may own the process of scientific naming, the patient history and interview, physical exam, treatment plan, and adherence, in order to be successful, require some degree of collaboration between clinician and patient. Toombs argues that if the clinician’s diagnosis is to become meaningful for the patient, the disease must be told not as an objective fact but in terms of the patient’s lived experience. Toombs writes, The fundamental insight that in the constitution of meaning there is an essential correlation between the experiencer and that which is experienced underscores the necessity of considering the manner in which each patient constitutes the meaning of her or her personal experience of illness.64  Toombs, 39, emphasis in original. In nursing and prehospital medicine, the patient’s description of the problem is segmented as the patient’s “chief complaint.” The chief complaint is considered symptom-specific, subjective, and useful for symptom-management. A well-articulated chief complaint may be useful in shortening the time to developing a working diagnosis and can be essential to life saving treatment and symptom management. However, the chief complaint is never diagnostic itself. 63  Toombs, 42. 64  Toombs, 26. What we ultimately get from Toombs is the reinforcement of well-articulated intentions by both clinician and patient. Toombs writes, “Consequently, it is a matter of some importance that physician and patient make it clear to each other just what each considers to be of primary importance in the therapeutic endeavor so that they may negotiate and collaborate on a system of care” (28). What Toombs advocates is the physician and patient constructing together a common, shared narrative that articulates their intentions as agents within and against a medical system that may have discordant and contradictory intentions of its own. “It is not easy for patients to communicate this experience to others” (28) she continues, which suggests the need for an intervention or discursive space (form/event) that could assist in not only helping the patient better articulate and explain their experience-with-disease, but also render such an activity in a way that could enhance the physician’s understanding and ability to engage within the patient’s experience. 62

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Toombs’ advocacy for rhetorical collaboration between the physician and patient (scientific and experiential) is consistent with and expected for patient-centered, humanities-based critiques of medicine. As the genre would have it, the physician, nurse, medic, is scolded for not effortlessly traversing between the clinical world of objective science and the patient’s immediate suffering—for not being able to fully articulate disease in terms of the patient’s continued lived experience. Such an articulation influences therapeutic success, patient adherence to medication, nosocomial infections and complications, and even hospital readmissions.65 But, there is more going on here. Returning to Gawande’s account in the New Yorker, he contrasts his own “heroic” experience as a surgeon with the incrementalist, distinctly non-heroic, long-term medicine practiced in family medicine, primary care, palliative care, and internal medicine. Gawande admits to an initial bias, suggesting that he approached his career initially thinking that his role as a surgeon had “more opportunities to make a clear difference in people’s lives.” However, over the course of the article, that bias is destabilized as he transitions us away from heroic care. “Primary care,” he foreshadows, “is the medical profession that has the greatest over-all impact, including lower mortality and better health, not to mention lower medical costs.”66 Gawande writes about being impressed with the relationships primary care physicians establish with their patients and the health benefits such relationships produce. Relationships allow physicians more time with their patients, more opportunities to uncover long-term solutions and preventative strategies that are not available to acute care providers, surgeons, and other episodic-driven specialists. “Success,” he argues, “is not  Specific examples here would include treatment plans relevant and specific to a patient’s day-to-­ day activities and life experience, prescribing medications that are affordable and with manageable and understood side-effects, therapy that is realistic and easily integrated into the patient’s living conditions, educational material that is accessible and relevant, proactively identifying, consulting, visiting, and working with patients at risk for readmission, recognizing the value and importance of incremental primary care, prenatal care, gerontology, and palliative care specialists. Such approaches are neither new nor novel and have been proposed over and again yet seem to stall even as systems struggle to meet CMS goals for readmission, infection, mortality, and the appropriate care for ambulatory sensitive conditions. 66  Gawande, 18 65

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about the episodic, momentary victories, though they do play a role. Success is about the longer view of incremental steps that produce sustained progress. That, such clinicians argue, is what making a difference really looks like.”67 In my first few weeks at the free clinic, I recall interviewing a patient complaining of a sore wrist and elbow. The patient’s vitals were normal, breathing was clear, and as someone trained in episodic emergency medicine I reported back to the physician that I was not entirely sure why the patient was here, “there doesn’t seem to be anything wrong.” Inviting me to shadow him for the rest of the evening, the primary care physician on duty that night explained that his role was not to think about the immediate, but to forecast how the current presentation could transform over the next 5–10 years. Primary care occurs in the future he explained, primary care physicians are always thinking down-­ the-­road, how might this develop? What complications could this lead to? What do we need to consider going forward? Such an approach can recognize problems long before they become complicated, before more invasive, expensive, and intensive care is required, and well before issues like hospital readmission become problematic. Such an approach would appear to fulfill Toombs’ requirements and the often-cited critiques for patient-centered care, for collaborative approaches to medicine, for aspirational ways to connect the clinical and experiential worlds, and for intentions to integrate significance and meaning. While we may know that such incrementalist approaches result in better patient outcomes, reduced costs, better quality of life, and less physician and caregiver burnout, our systems fail to appropriately incentivize them. Knowing that it is the physician’s intention to diagnose and the patient’s intention to return to lived experience suggests an approach to healthcare that would incentivize early recognition and proactive diagnosis structured toward preserving and enabling day-to-day activities. Yet, American healthcare incentives are aligned entirely toward expensive, emergent, episodic treatment. As Gawande notes, his incrementalist anti-­ heroes of healthcare are the lowest paid specialists in medicine.68 “As an  Gawande, 18.  Gawande lists the lowest paid specialists in medicine to be “pediatrics, endocrinology, family medicine, H.I.V./infectious disease, allergy/immunology, internal medicine, psychiatry, and rheumatology” (22). 67 68

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American surgeon, I have a battalion of people and millions of dollars of equipment on hand when I arrive in the operating room” Gawande writes. “Incrementalists are lucky if they can hire a nurse.” These incentives are strong. Todd, a medical student and friend who has volunteered at the free clinic for three years, tells me he would like to go into primary care or family medicine. However, he notes, realistically but with a touch of cynicism, starting salaries in cardiology and orthopedics are orders of magnitude higher than family care. His choice is between paying off his school debt in less than two years or carrying that debt for more than a decade. The stark discrepancy in income, resources, and status among these anti-heroes is only one indication of a system with discordant and dysfunctional intentions. Sickness produces consumers who generate demand in the form of laboratory tests, radiological scans, prosthetics, operating room time, pharmaceuticals, diagnostic procedures. Sickness, in American healthcare, manifests as both a reward and a punishment. Physicians are rewarded, and thereby incentivized, for their ability to generate and spread revenue throughout the system. An intentional analysis of actions and actors here shows that American’s concerns about a non-market approach to healthcare have nothing to do with access, patient care, cost, physician autonomy, individual patient outcomes, or public health outcomes.69 Realistically, a non-market-based approach to healthcare generates a comparable pittance for an investor class.

 This is not the space to adjudicate the relative merits of healthcare systems; however, an extensive literature, both domestic and foreign, has shown that single-payer-based systems achieve better results than the current U.S. system in each of the metrics: access, patient care, cost, physician autonomy, individual patient, and public health outcomes. See for example, Galea, S. (2017). “Is the U.S. ready for a single-payer healthcare system?” Harvard Business Review July. Retrieved from, https://hbr.org/2017/07/is-the-u-s-ready-for-a-single-payer-health-care-system. For an international perspective, see, Ridic, Goran, Suzanne Gleason, and Ognjen Ridic. 2012. Comparisons of healthcare systems in the United States, Germany, and Canada. Materia Socio Medica 24: 112–120. Ridic, Gleason, and Ridic conclude, “Compared to the US system, the Canadian system has lower costs, more services, universal access to health care without financial barriers, and superior health status. Canadians and Germans have longer life expectancies and lower infant mortality rates than do US residents” (120). See also, Yu, Jia and Yi Zhang. 2017. Comparison of single-payer and non single-payer health care systems: A study of health administration efficiency. Modern Economy, 8: 816–833. https://doi.org/10.4236/me.2017.86057 69

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The Ratios II  gency/Scene/Purpose: Finance, the Electronic A Medical Record, and Terministic Screens Whereas Victorian morality saw sickness as punishment for sin, consumerist culture rewards sickness that generates revenue with limitless and subsidized access to any service, device, test, or drug their insurance procures for them. As Richard Harvey-Brown wryly notes about American consumerism, “the new consumerism favors indulgence more than discipline and validates the desires of the self, its feelings, its expression, and its fulfillment, especially as these can be gratified in consumption.”70 Translated to healthcare, this indulgence is a system eager and ready to provide more and more treatment for those who can pay for it. At the same time, those unable to transform sickness into revenue (uninsured, under-insured), those unable to act as healthcare consumers, are punished with a lack of access and restriction from treatment. A well-insured patient with an infectious disease merits a private suite and expert consultations while hypothyroidism in an uninsured 35 year old elicits banishment. The American health system’s intention as a consumer and profit-­ centered industry was correctly anticipated by Paul Starr who, concluding his historical study of the American healthcare system, wrote, The rise of a corporate ethos in medical care is already one of the most significant consequences of the changing structure of medical care. It permeates voluntary hospitals, government agencies, and academic thought as well as profit-making medical care organizations. Those who talked about “health care planning” in the 1970s now talk about “health care marketing.” … The organizational culture of medicine used to be dominated by ideals of professionalism and voluntarism, which softened the underlying acquisitive activity. The restraint exercised by those ideals now grows weaker. The “health center” of one era is the “profit center” of the next.71 70 71

 Brown, 150 (see note 204 above).  Starr, Paul. 1982. The Social Transformation of American Medicine. New York: Basic Books, 448.

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Other sectors of the American economy have not overlooked the economic opportunities available within healthcare’s new revenue-­generating intention. As noted above, some of the most ambitious attempts to modernize and change American healthcare involved the monumental adoption of data-intensive healthcare information technology systems. In nearly every clinical encounter across the modern American healthcare landscape, an electronic medical record (EMR), the centerpiece of $19 billion in federal government incentives, now serves as the primary tool for mediating the patient physician experience. If Toombs taught us to be concerned about unequal power and disciplinary relations that segmented and disaggregated physician and patient intentions, the adoption and implementation of the EMR have shown that modern healthcare and corporate capitalism have successfully intertwined to the extent that Toombs’ critique now seems nostalgic. The physician’s reconstruction of the patient’s clinical history and narrative is the primary form and event enacted in the patient encounter. This face-to-face encounter has been, perhaps, the sole surviving formal space Toombs would acknowledge provides opportunity for a communicative common environment between the patient and the physician. In the medical literature, the patient narrative is recognized as the patient’s own accounting of why the patient is consulting the clinician. Lisa Sanders writes that the patient narrative is the physician’s oldest and most reliable tool estimating that between 70 and 90% of diagnosis are made on the basis of the narrative alone.72 The National Academies of Science, Engineering, and Medicine’s 2015 report, Improving Diagnosis in Healthcare, explains that the process of obtaining a clinical history from the patient is essential to establishing a foundation for the patient-­ physician relationship.73 The clinical history, as described by the National Academies, supports much of Toombs’ requirements for model encounters, arguing that the interview requires “effective communication, active  Sanders, Lisa. 2009. Every Patient Tells a Story: Medical Mysteries and the Art of Diagnosis. New York: Broadway Books, 6. 73  Committee on Diagnostic Error in Health Care; Board on Health Care Services. Institute of Medicine, The National Academies of Sciences, Engineering, and Medicine. 2015. Improving Diagnosis in Health Care, ed., Erin Balogh, Bryan Miller, and John Ball. Washington, DC: The National Academies Press. https://doi.org/10.17226/217942015), 36 72

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listening skills, and tailoring communication to the patient based on the patient’s needs, values and preferences.” The effective clinician will “create a safe environment for patients to share sensitive information about their health and symptoms.” Further, they recommend that the process take place without interruption, that the physician demonstrate empathy, and throughout use the interview as an opportunity to establish rapport with patients.74 Structurally, the patient’s narrative is understandably influenced by experience, by the patient’s personal understanding of symptoms, and the patient’s communication abilities.75 Using basic language from narrative theory, Baerheim writes that the patient’s “clustering of signs and their development over time” can be recognized as “the plot” of a patient’s “illness story.” Clustering “inter-related symptoms developing over time” guides the physician toward appropriate diagnostic tests and to the eventual diagnosis.76 Thus, in ideal practice, the patient narrative is a collaborative process in which physician and patient together create a story that represents the patient’s most intimate experiences and anxieties. This story is then co-­ edited and reiterated by the physician until the story successfully incorporates the diagnosis and affliction back into the patient’s life. Even in cases where patients represent themselves as “unreliable narrators,” this very subject position is useful for the physician’s assessment and ultimate reintegration of the story and the patient’s experience. Initially, the EHR was proposed to aggregate and store patient data from the EMR’s multiple visits, sites, and events. Proponents claimed that the technology would enable system-wide coordination, enable retrospective research, and enable researchers and clinicians to discover the “whys” behind their numbers. Yet, despite the centrality of the patient narrative to the diagnostic process, the adoption of electronic clinical technologies has excised the patient narrative from the diagnostic process and record. The EMR has made patient narratives difficult and at times  Committee on Diagnostic Error in Health Care et al., 36.  Baerheim Andeers. 2001. The diagnostic process in general practice: Has it a two-phase structure? Family Practice 18: 243–45, 243. 76  Baerheim, 244. 74 75

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technically impossible to capture and archive. The technology has substituted boiler-plated and redundant text for the patient’s free-flowing narrative and thus made the central component of the diagnostic encounter inaccurate. Most experts now concede that computer-generated narratives are bloated, inaccurate, and useless for diagnostic purposes.77 Sanders writes that this new affordance, availability, and reliance on technologically-mediated diagnoses have pushed the patient narrative to the margins of medical practice. She notes that “over half of the patients interviewed after seeing their doctor had symptoms that they were concerned about but did not have a chance to describe.”78 Here, the process of acquiring the patient narrative has devolved into a physician interrogation in which patients are now regularly interrupted by questions as physicians check required content boxes presented by the digital record. These interruptions, their lack of empathy and failed rapport, result in and reinforce the dysfunctional physician-patient dynamics much of the critical literature in medicine has attempted to repair.79 If time constraints, improved technology, and poor listening skills have eroded the patient narrative, the transition to electronic medical records has further eroded what is not only a vital heuristic but also a crucial bridge between the patient and the physician. As clinical applications, electronic medical records provide clinicians with pre-established categories, boxes which, when selected, digitally construct the patient narrative. These categories (represented by check-­ boxes) are generated by complaint-specific templates. If a patient encounter is due to trauma, a separate set of selections are made available than if the patient encounter is due to chronic disease. Similarly, disease selections can be structured to provide, in nosological templates, detailed  Gantzer, Heather, Brian Block, Lacy Hobgood, and Janice Tufte. 2020. Restoring the story and creating a valuable clinical note. Annals of Internal Medicine 173: 380–382. 78  Sanders, 7. 79  For Humanities critiques of the language of dysfunctional patient/physician encounters, see: Mishler, Eliot. 1984. The Discourse of Medicine: Dialectics of Medical Interviews. Norwood NJ: Ablex. Fairclough, Norman. 1992. Discourse and Social Change. London: Polity. Fleischman, Suzanne. 2003. Language and medicine. In The Handbook of Discourse Analysis, ed. Deborah Schiffrin, Deborah Tannen, and Heidi Hamilton, 470–502. Oxford: Blackwell. Ainsworth-­ Vaughn, Nancy. 2003. The discourse of medical encounters. In The Handbook of Discourse Analysis. ed. Deborah Schiffrin, Deborah Tannen, and Heidi Hamilton, 453–69. Oxford: Blackwell. 77

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taxonomies to guide the physician through the encounter and ultimately to justify (billing for) the diagnosis. While the EMR ensures comprehensive coverage of condition-specific complaints (asking questions pertinent to the specific condition and providing sufficient data to justify insurance billing), the patient narrative becomes technologically transformed into a series of point-and-click activities with pre-scripted narrative vocabulary automatically generated by the physician’s selections. The pre-scripted text replaces the patient’s actual language as the history in the electronic archive. While “free texting” can be an option for recording the patient’s actual narrative in some electronic systems the option is time consuming, difficult to integrate within the digital archive, irrelevant for billing, and impossible to utilize for retroactive chart review, outcomes assessment, and analytics. In a practical, clinical example, Janet Dillione (2011) describes a situation in which two women presenting in an emergency department with broken ankles would generate similar check-boxed patient narratives documenting time of arrival, course of pain (constant), location of pain (left foot), location of bleeding (none), and assessment (broken left foot).80 Whereas a richer patient narrative would capture that woman #1 had a donut with jam for breakfast—rather than her usual bagel—and became dizzy upon running up the stairs to get the phone. Woman #2 fell while playing soccer in the backyard with her grandchildren. The importance of the nuanced account of patient #1’s narrative indicates a potential yet-unknown issue with blood sugar, a diagnostic indicator that would not ordinarily be captured by the EMR. As Dillione’s example demonstrates, the EMR technologically reverses the narrative heuristic— prompts and pre-structured language compose the narrative, not the collaborative activity between the patient and physician. In 2002, Patel, Arocha, and Kushniruk, writing in the Journal of Biomedical Informatics, reviewed early EMR implementation and use with an emphasis on how the EMR influenced physician-patient communication and the resulting medical decision-making. The authors’  Dillione, Janet. 2011. Electronic medical records: How they affect patient care. Huffington Post. 15 June (Updated 15 August). http://www.huffingtonpost.com/janet-dillione/electronic-medical-­ records_b_872343.html Accessed 4 January 2022. 80

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findings were consistent with much of what we know, physicians framed medical problems using pathophysiological knowledge and focused on the underlying disease. Patients framed the issue using narrative structures of illness, emphasizing the disruption of normal daily activities.81 The authors concluded that while the physician-patient interview remains a vital component of the medical encounter, the EMR’s functionality influenced how and what data was gathered. As a consequence they reported, important temporal and sequential information was lost from the patient narrative. The authors wrote, “use of the EMR was associated with fundamental changes in the way that information was recorded. Specifically, use of the EMR was associated with a change from the entry of information as a connected narrative in the paper record, to the entry of information as discrete information units in the EMR.”82 The EMR recorded discrete bits of information: patient age, chief complaint, ­surgical history, medical history, medications, and displayed that information in disaggregated data points. Patel et al. refer to this as “screen driven behavior” as the EMR, and not the patient, sequenced the patient history and narrative.83 Patel et al. cautioned that by prioritizing discrete units of medical data, the EMR’s overly structured data requirements limited and distorted the physician’s reasoning, and could impede making an accurate or effective diagnosis and treatment plan.84 They concluded by recommending new components within the EMR that could better capture the patient narrative and patient perspective of illness. Thirteen years later, writing in the International Journal of Medical Informatics, Lara Varpio and colleagues argued that “Building the patient’s story is an essential part of clinical reasoning activities” and “The use of an EHR can obstruct clinicians’ ability to build the patient’s story and to disseminate it to other members of the team.” They note that the

 Patel, Vimla, José Arocha, André Kushniruk. 2002. Patients’ and physicians’ understanding of health and biomedical concepts: relationship to the design of EMR systems. Journal of Biomedical Informatics 35: 8–16, 11. 82  Patel, 14. 83  Patel, 15. 84  Patel, 15. 81

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obstruction was created by “fragmenting patient data interconnections and limiting the spaces available for narrative notes.”85 In addition to technologizing and distorting the patient’s illness narrative, EMRs have been shown to significantly increase redundancy within the chart.86 Because each physician “click” generates pre-scripted language throughout the EMR, multiple points of information are duplicated in each section of the chart. This is an important finding because increased redundancy means that hurried clinicians are presented with duplicative and unnecessary information, reducing the value of the digital text and forcing many of them to skip the assessment section entirely and jump directly to quantitative test results. In an intriguing twist, the excision of the patient narrative from electronic medical records has also been a considerable concern and point of contention for technical researchers. Ash, Berg, and Colera found that “overly structured data entry led to a loss of cognitive focus” by physician users. This loss of focus meant that clinicians often experienced a “loss of overview” of the patient. Because they comment on the act-of-writing and the function of invention in the creation of the medical record, Ash, Berg, and Colera’s comments are worth citing in full,

 Varpio, Lara, Judy Rashotte, Kathy Day, James King, Craig Kuziemsky, and Avi Parush. 2015. The EHR and building the patient’s story: A qualitative investigation of how EHR use obstructs a vital clinical activity. International Journal of Medical Informatics 84 (12): 1019–1028, 1027 (emphasis in original). See also: Doberne, Julie, Roheet Kakaday, Travis Redd, Carl Eriksson Thomas Yackel Jenna Marquard, Jeffrey Gold, Vishnu Mohan, Joan Ash, and Michael Chiang. 2015. Barriers to information access in electronic health records during initial patient visits: A qualitative study. Proceedings of the International symposium on Human Factors and Ergonomics in Health Care 4: 143–149. https://doi.org/10.1177/2327857915041009; Clynch, Neil and John Kellett. 2014. Medical documentation: Part of the solution, or part of the problem? A narrative review of the literature on the time spent on and value of medical documentation. International Journal or Medical Informatics 84: 221–228. Clynch & Kellett write, “Unlike the paper chart narrative is difficult to enter into most EMRs so that they do not adequately communicate the patient’s ‘story’ to clinicians” (224). 86  Wrenn, Jesse, Daneil Stein, Suzanne Bakken, and Peter Stetson. 2010. Quantifying clinical narrative redundancy in an electronic medical record. Journal of the American Medical Informatics Association 17: 49–53. Cam, Kenneth, Efthimis. Efthimiadis, and Kenric. Hammond. 2008. An investigation of the use of computerized patient care documentation: Preliminary results. Proceedings of the 41st Hawaii International Conference on System Sciences. https://doi.org/10.1109/ HICSS.2008.63 85

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When professionals are working through a case, determining a differential diagnosis, for example, the act of writing the information is integral to the cognitive processing of the case. This act of writing-as-thinking can be aided greatly by some structure such as the grouping of similar types of information or sequencing to guide elucidating a history but is inevitably hampered by an excess of structure. Rather than helping the physician build a cognitive pattern to understand the complexities of the case, such systems overload the user with details at odds with the cognitive model the user is trying to develop.87

Similarly, writing in 2011, Vineeth Nair and colleagues conclude “template-driven electronic health record systems often provide too constrained a structure for the clinician to represent a patient’s unique health ‘story.’”.88 Nair et al. write that data stored in the EHR’s pre-determined fields leads to the loss of contextual information—which reduces the physician’s ability for nuance and overly complicates the patient story with irrelevant and unnecessary data (similar to Cam et al.’s finding of redundancy above). An overly redundant patient narrative filled with unnecessary documentation means that this section of the patient’s chart becomes buried and lost to the clinical process and future users of the digital information. If clinicians, humanities scholars, technical users, and even the very designers of electronic medical records have shown that their architectures distort the diagnostic process, further alienate patients and physicians, and can be detrimental to patient outcomes, what can be the motivating intention for the system’s structure and design? The answer, by now, should not be surprising. James Shaha and colleagues, argue that the gap in satisfaction among clinical EHR users is because the systems  Ash, Joan, Marc Berg, and Enrico Colera. 2004. Some unintended consequences of information technology in health care: The nature of patient care information system-related errors. Journal of the American Medical Information Association 11: 104–12, 109. See also, Congdon, Ken. 2012. Save the clinical narrative. Healthcare Technology Online, 3 March. http://www.healthcaretechnologyonline.com/article.mvc/Save-The-Clinical-Narrative-0001 88  Nair, Vineeth, Milind Kaduskar, Pratibha Bhaskaran, Sandip Bhaumik, and Hodong Lee. 2011. Preserving narratives in electronic health research. Proceedings of the IEEE International Conference on Bioinformatics and Biomedicine. IEEE Computer Society: 418–21, 418. 87

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were established for medical administrators and information technology professionals and “their needs are given higher priority than those of clinicians.” Despite whatever terministic screens may have been used to implement the EMR, when we examine its use-value, what the technology does and what actions it supports, the intent here has been to streamline billing and make the hospital’s revenue cycle management more efficient, predictable, and better integrated between healthcare systems and insurance and government payors.

 he Tragedy of Drama: Act, Scene, Agent, T Agency, Purpose Toward the end of his essay “Terministic Screens,” Kenneth Burke defines dramatism as “A technique of analysis of language and thought as basically modes of action rather than as means of conveying information.”89 Turning Burke’s concept toward a rhetoric of intention in medical systems, I have attempted to use his terminology to recognize and describe how these systems and structures accomplish actions within and against their rhetorical claims. It is important to reassert that this is an examination of system and not of specific agents. The drama here is tragic because so many people are deeply committed to the promises and intentions of a medical system that is meaningful for the ways clinicians diagnose and treat injury and disease, save lives, prevent harm, and build lasting, life-­ long relationships with their patients. While considerable discourse in medicine appears focused on diagnosis, illness, disease, treatment, care, patients, and recovery; actions in the larger system appear increasingly disinterested in such discursive formations when sickness, injury, and illness can aggregate increasingly lucrative value streams. In this way, intention-as-action evokes a rearticulation of Burke’s Terministic Screen. Examining intention through action deploys “screen” not as an interpretive device, nor as a framework or lens through 89

 Burke, 1966, 55.

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which one perceives the world. Instead, screen becomes rhetorical cover and a distraction from actions. Here Burke switches from screen as an interpretive to a performative device. Such terministic screens provide means to pursue a course of action under the cover of discursive abstraction. And, for all of its competing intentions, the American medical system could represent a quintessential terministic screen.

6 Practice: Heuristics and Hermeneutics in Data Science

By discovering the “secret order” of nature, science was seen, and culturally posited, as providing a rational access to the divine plan of creation, as being a way of ascertaining God’s intentions with the world at large… Gyorgy Markus, “Why Is There No Hermeneutics of Natural Science?” (Markus, Gyorgy. 1987. Why is there no hermeneutics of natural sciences? Some preliminary theses. Science in Context, 1: 5–51.) The drive to institute metrics often arises from the best of intentions, as a purported solution to real problems. Jerry Z. Muller, The Tyranny of Metrics (Muller, Jerry. 2018. The Tyranny of Metrics. Princeton: Princeton University)

This chapter examines the rhetorical work of analytics and its product, quantitative metrics, as a constructive strategy of intention. This chapter situates analytics as a heuristic process, the intentional curation of data to evoke change within systems. Despite its reputation as a quantitative and computational field, analytics is equally, or perhaps even more so, a societal, behavioral, and rhetorical (humanistic) activity. While scholars across textual studies have shown some interest in big data and analytics, not enough work has emphasized or instrumentalized the contextual and © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 B. Faber, The End of Genre, Postdisciplinary Studies in Discourse, https://doi.org/10.1007/978-3-031-08747-9_6

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societal dynamics of the practice. Like any rhetorical activity, analytics impose value and intention. While analytics are equally computational and interpretive, much more work has emphasized and developed the computational side of the field even while acknowledging deficits in how meaning is interpreted from such data and in the ethical uses of big data.1 From simple metrics like heart rates and blood pressures to more complex and interpretive ones like patient outcomes, consumer behavior, and voting patterns, queries invent and aggregate descriptions, assessments, and predictions that are intended to change human behavior.

Evoking Transparency In arguing that analytics is an intentional strategy, I want to emphasize that, unlike creative processes that often blackbox or mysticize method, analytics has claimed a transparent system for gathering and prioritizing information. Such transparency is also supposed within the behavioral objectives that metrics evoke. This is not to suggest that analytics is somehow value neutral. But that as a rhetoric, advocates of metrics, big data, and analytics claim a transparent ability to know and determine the data by which something is being measured, evaluated, and incentivized. In this way, analytics claims to overtly build intention into the process of  See for example, Zook Matthew, Solon Barocas, Danah Boyd, Kate Crawford, Emily Keller, Seeta Peña Gangadharan, Alyssa Goodman, Rachelle Hollander, Barbara Koenig, Jacob Metcalf, Arvind Narayanan, Alondra Nelson, and Frank Pasquale. 2017. Ten simple rules for responsible big data research. PLoS Computational Biology 13: e1005399. https://doi.org/10.1371/journal. pcbi.1005399. Zook et al. write that “As the size and complexity of available datasets has grown, so too have the ethical questions raised by big data research. These questions become increasingly urgent as data and research agendas move well beyond those typical of the computational and natural sciences, to more directly address sensitive aspects of human behavior, interaction, and health.” Arguing that “the need for direction in responsible big data research is evident” they offer ten rules for big data researchers, including “acknowledge that data are people and can do harm”; “recognize that privacy is more than a binary value”; and “engage with the broader consequences of data and analysis practices.” Similarly, Cristian Calude and Giuseppe Longo argue that computational analysis of big data tends toward the validation of spurious and arbitrary correlations due to the size and not the nature of the data (see, Calude, Cristian & Giuseppe Longo. 2017. The deluge of spurious correlations in big data. Foundations of Science 22: 595–612. https://doi.org/10.1007/ s10699-016-9489-4) 1

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assessment: By showing what is measured, the process of assessment directly incentivizes behaviors and thereby embeds intention within a system. Analytics has made the expressions “You are what you measure,” “you get what you measure,” and “what gets measured gets done” folk knowledge in management, engineering, and process improvement disciplines. Critics will appropriately disagree with what is measured. Additionally, others dismiss analytics out of hand by claiming that their privileged behaviors or outcomes are things that cannot be quantified. Some of that criticism can be accurate and has been well documented. Instead, this chapter seeks to change that discussion by examining the role of intention within metrics and examining if the new tools of data science can be mapped to a more intentional humanities. Claiming disagreement with what is being measured is not a sufficient argument against measuring. Nor is claiming a privileged space beyond measurement a reason to elide analytics all together.

Analytics and Rhetorical Heuristics Definitions of analytics can be field-dependent but most accounts ground the field in the tools of databases, logistics, and business intelligence. For example, advocates of business intelligence routinely describe how consumer purchasing, inventory, or employee performance data can be mined for strategic opportunity. Other researchers have extended the promise of analytics and big data to fields like healthcare through applications in epidemiology, bio-statistics, genomics, and clinical decision-­ making. More discrete data mining practices have been subtle and disturbingly innovative. Take, for example, the free video games available for mobile phones, pads, and computers. The value in these games is not the gaming experience but the data the games collect and then commercialize about users: How frequently and when a user plays the game and the geographic locations of frequent users. Apps can report decisions, gaming habits, and routine choices users make while playing a game. The game can report when users take a break and how often they return, plot

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twists and other game details that extend playing time. More sophisticated algorithms claim to decipher players’ personalities and psychological and character traits from how the game is played. Is the user impulsive or carefully deliberate? When faced with decisions or risky events does the user seek collective activity or is the user more likely to go it alone? Phone apps can use and remember locations, purchases, preferences, and games and then compare a user’s profile to other profiles close by. If my phone discovers another phone that has frequented the same retail stores and restaurants, or recognizes a common running route or digital subscription, the two phones can recognize each other and swap user information—a big data algorithm for instant friendships.2 Heuristics are a component of the first Rhetorical cannon invention, which is followed by arrangement, style, memory, and delivery. While more currently associated with decision-making and problem solving, classically, heuristics provided orators with formal structures for speech making.3 Aristotle’s Rhetoric, for example, provides separate taxonomies for political, legal, and celebratory arguments. Each taxonomy provides the form for its respective argument. For example, a political argument, an argument concerning whether or not to do something, Aristotle offers, should address the future and will establish either the expediency or harmfulness of the proposed activity. Expedience or harm can be established through ways and means (economics), war and peace, national  Kashmir Hill, in an article published on splinternews.com, examines a Facebook feature that used a smart phone’s location data to suggest new friends to users. The app, called “people we may know,” was reported to use a phone’s location data to find intersections among social networks. Hill cites a Facebook spokesperson who stated, “We show you people based on mutual friends, work and education information, networks you are part of, contacts you’ve imported and many other factors.” Among the “many other factors” included location information. The problem here is that the app can de-identify people who attend anonymous events such as a man who claimed to Hill that Facebook tracked his location to a meeting for suicidal teens and identified another anonymous parent as a “person you may know.” Hill rightly explains other scenarios where the app could be problematic or even dangerous for users. In an update to the story, Hill writes that Facebook appears to have discontinued using location as part of the “friends” algorithm (see, Hill, Kashmir 2016). Facebook is using your phone’s location to suggest new friends—which could be a privacy disaster. SplinterNews.com, June 29. https://splinternews.com/facebook-is-using-your-phoneslocation-to-suggest-new-f-1793857843 3  Kahneman, Daniel, Amos Tversky, and Paul Slovic, Eds. 1982. Judgment Under Uncertainty: Heuristics & Biases. Cambridge, UK, Cambridge University Press 2

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defense, or domestic security. Domestic security is established by claims about future happiness. Future happiness is defined as “a good birth, plenty of friends, good friends, wealth, good children, plenty of children, a happy old age, also such bodily excellences as health, beauty, strength, large stature, athletic powers, together with fame, honour, good luck, and virtue.”4 The arguments follow Aristotle’s blueprint, with the inclusion of timely and contextually relevant examples. More contemporary heuristics have included tools such as the journalist’s who, where, why, what, and when; Kenneth Burke’s pentad for articulating a dramatistic scene, and more informal structures such as common brainstorming, creating lists, or the dreaded three-paragraph essay. Like heuristics, analytics is concerned with the efficient transformation of raw and unstructured data into quantitative forms for problem-solving and content creation. Advocates of analytics claim that massive amounts of digital data produced by digital commerce, web searches, job applications, location detectors on digital devices, electronic medical records, databases, and across what has come to be known as the internet of things create opportunities to describe complex systems, evaluate processes, predict or determine future events, and most importantly incentivize and thereby change behavior. Professional sports have probably done more to popularize analytics than most industries, specifically Major League Baseball and Oakland Athletics former manager and now executive vice-­ president Billy Beane. Beane’s now well-known and widely replicated analytics-based coaching methods led to a full reassessment of baseball strategy, recruiting, and the metrics used to interpret the game. Beane’s approach became known as Sabermetrics and has been the subject of numerous profiles including the book and movie Moneyball.5 MIT has a yearly conference investigating analytics and athletics and ESPN The Magazine produces a yearly analytics issue.6 In politics, analysts have been able to predict someone’s inclination to donate to a campaign, their

 Aristotle. On Rhetoric, Book 1, part 5. http://classics.mit.edu/Aristotle/rhetoric.1.i.html  Lewis, Michael. 2004. MoneyBall: The Art of Winning an Unfair Game. New York: W.W. Norton. 6  For information on the MIT Sloan Sports Analytics Conference, see: http://www.sloansportsconference.com/. Accessed 5 August 2018. 4 5

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likelihood to vote, and the ability of specific advertisements to generate action within very specific and precise demographic subsets.7

 nalytics and Meaning Making: What A Is Hypertension? Davenport and Harris define analytics as “the extensive use of data, statistical and quantitative analysis, explanatory and predictive models, and fact-based management to drive decisions and actions.”8 In this way, metrics are much like system-wide vital signs. Like vital signs, metrics appear to offer an efficient, simple, and clear picture of what is going on within and across a large and complex system. But, like vital signs, what the information actually means, what story is being told, and what we should do with the information generated is not always obvious. As guides for thinking, problem-solving, content generation, and even ethical deliberation, heuristics are efficient, quick, and useful, but heuristics are not context sensitive and, given their typical superficiality, not very useful for complex problems. Take, for example, blood pressure monitoring, a commonly used medical metric (vital sign). Chronic hypertension (high blood pressure) is widely recognized as one of the most preventable risk factors associated with disease and premature death. In an acute emergency setting, monitoring how blood pressure trends over time is a useful way to recognize if  The claim here is that analytics and big data have become central to political strategy not that their use in 2012 and 2016 was equivalent. For information on the 2012 campaign, see note 130. On Cambridge Analytica and the illegal harvesting of private Facebook data, see: Rosenberg, Matthew, Nicolas Confessore, and Carole Cadwalladr. 2018. How Trump consultants exploited the Facebook of millions. New York Times, 17 March. https://www.nytimes.com/2018/03/17/us/politics/ cambridge-­analytica-trump-campaign.html. Accessed 5 August 2018. An important distinction here is that in 2012 analysts used polling data and data from their own surveys, phone calls, and campaign operations while in 2016 social media data was taken from over 50 million Facebook users without their permission. Of course, the use of analytics in elections is not limited to American politics. Susan Ormiston a reporter for the CBC, for example, has described how all three major Canadian political parties have used data mining in federal elections. See Ormiston, Susan. 2015. Federal election 2015: How data mining is changing political campaigns. CBC.ca, http://www.cbc.ca/news/politics/federal-election-2015-how-data-mining-is-changing-political-­ campaigns-1.3211895. Accessed 5 August 2018. 8  Davenport, Thomas and Jeanne Harris. 2007. Competing on Analytics: The New Science of Winning. Cambridge MA: Harvard Business Press, 7. 7

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a patient’s condition is deteriorating. An extremely low or high blood pressure can point to immediate and potentially reversible life threats. Over months and years, tracking blood pressure can also point to early signs of chronic disease. But how to define hypertension and when is hypertension meaningful (rather than merely significant)? In 2017, the American College of Cardiology and the American Heart Association lowered the diagnostic threshold for hypertension to 130–139 mm Hg systolic.9 The 2017 report recommended that healthy individuals maintain a normal blood pressure measure below 120/80 mm Hg. The guidelines also included three new hypertension categories: Elevated (120–129 mm Hg systolic with a diastolic pressure lower than 80 mm Hg), Stage 1 hypertension (130–139 mm Hg systolic and 89–90 mm Hg diastolic), and Stage 2 hypertension (140/90 mm Hg or higher). The recommendations were controversial. I rarely see a systolic blood pressure below 140 in my healthy patients. Or, to put it differently, in prehospital care, unless the patient is an 18-year-old athlete, a systolic blood pressure lower than 120 can be worrying. I’ve had patients call us for completely unrelated issues who have systolic pressures upward of 150 mm Hg and surprisingly few complaints consistent with hypertension. On average, if I had to pick a number, I’d estimate that most of our patients measure between 130–150 mm Hg systolic. One evening we saw a 65-year-old female in good health who came to the free clinic for a routine physical check-up. Her heart rate was 75 and regular, but her blood pressure was 140/90, which was outside of the 120/80 heuristic for a healthy patient. The patient denied headache, dizziness, shortness of breath, chest pain, dental pain, or vision problems. In conversation, the patient noted that a systolic pressure of 140 was “fairly normal” for her and often was higher when measured because she felt nervous at the doctor’s office.  Whelton Paul, Robert Carey, Wilbert Aronow, Donald Casey Jr., Karen Collins, Cheryl Dennison Himmelfarb, Sondra DePalma, Samuel Gidding, Kenneth Jamerson, Daniel Jones, Eric MacLaughlin, Paul Munter, Bruce Ovbiagele, Sidney Smith Jr., Crystal Spencer, Randall Stafford, Sandra Taler, Randal Thomas, Kim Williams Sr, Jeff Williamson, and Jackson Wright Jr. 2017. ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Hypertension. 2018: 71:e13–e115. doi: https://doi.org/10.1161/HY,000000 0000000065 9

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This patient would be considered Stage 2 hypertensive according to the 2017 guidelines and should be on aggressive anti-hypertension medication. But, according to 2014 evidence-based guidelines published in the Journal of the American Medical Association this patient should have little, if anything, to worry about. The JAMA consensus report argued that there is “strong evidence to support treating hypertensive patients aged 60 years or older to a BP goal of less than 150/90 mm Hg” and the authors recommended a blood pressure goal of 140/90 mm Hg.10 Writing about the 2017 report which set the new guidelines for aggressive anti-hypertension therapy, George Bakris and Matthew Sorrentino, both physicians, were critical of the guideline, and the new “elevated,” “stage 1,” and “stage 2” categories. They argued, “The guideline creates a new level of disease affecting people previously deemed healthy.” They note that about 16% of the U.S. adult population could now be newly diagnosed with hypertension, increasing the population with hypertension from approximately 32% of the U.S. population to about 46%. At the same time, by increasing the prevalence of the disease, the metric simultaneously increases the necessity for treating the disease and the many interventions and costs that such treatment could require (and reward).11 As the above example shows, analytics, as heuristics, promise content generation, but heuristics do not guarantee a comprehensive analysis or robust understanding of the problem or question being considered. Analytics can show significance but rarely meaning. A target blood pressure measurement is efficient but rarely very meaningful. Nor do heuristics consider the critical questions associated with the appropriate collection and use of information and the ethics of data acquisition and deployment. In the same way that a good recipe does not require an  James Paul, Suzanne Oparil, Barry Carter, William Cushman, Cheeryl Dennison-Himmelfarb, Joel Handler, Daniel Lackland, Michael LeFevre, Thomas MacKenzie, Olugbenga Ogedegbe, Signey Smith, Laura Svetkey, Sandra Taler, Raymond Townsend, Jackson Wright Jr., Andrew Narva, and Eduardo Ortiz. 2014. Evidence-Based Guideline for the Management of High Blood Pressure in Adults Report From the Panel Members Appointed to the Eighth Joint National Committee (JNC 8). Journal of the American Medical Association 311: 507–520. doi:https://doi. org/10.1001/jama.2013.284427 11  Bakris, George and Matthew Sorrentino. 2018. Redefining hypertension—Assessing the new blood-pressure guidelines. New England Journal of Medicine 378: 497–499. https://www.nejm.org/ doi/10.1056/NEJMp1716193 10

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understanding of chemistry, energy transfer, digestion, toxicity, or metabolism, heuristics are good enough to get by without necessitating extensive or even a particularly accurate understanding of a problem. As Aristotle knew, in heuristics, expedience is everything.

Intention in Metrics: The Power of the Join As an information-seeking activity, analytics can be framed as a modern form of heuristics, activities involved in the formal and informal generation of ideas and rhetorical content. We could use the term “electronic heuristics” or “algorithmic heuristics” to refer to such software-and-­ algorithm-­based data mining tools. Using insights about an audience to create a more compelling argument has been a cornerstone of persuasion since before the Georgias. Being able to work from data sets that can isolate groups of people who match specific interest group or identity-­ profiles is something a classical Sophist could never imagine. Being able to isolate potential customers/patients/donors/members/voters/advocates and communicate with them when an algorithm suggests they are vulnerable to suggestion introduces an entirely new kind of rhetoric more commonly associated with science fiction. The heuristic potential of big data increases when datasets are brought together (joined) and correlated. Here analytics is both a method and an interpretive practice, an intentional aggregation of new tools and old rhetorical theory. Aggregating behavioral data from months of computer game activity with consumer purchasing data, cell phone location data, smart watches, and demographics creates intersections of data that can measure, predict, or even elicit desired behaviors. Electronic heuristics have become more refined and successful and have produced startling and disturbing results in actual practice. For example, Charles Duhigg, writing in the New York Times Magazine, recounted, in 2012, how the retail company Target all too accurately used data mining from customer purchases to predict if women customers were newly pregnant.12 Not only are babies expensive, but if a retail store like Target can convince 12

 Duhigg, D., see note 126.

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new parents to stop in for baby goods, mom and dad will take advantage of the convenience to also buy groceries, household goods, clothing, back-to-school equipment, and healthcare products. Historical sales data was able to show that several months before women purchased diapers and baby food, they also purchased things like oversized bags, unscented moisturizer, vitamin supplements, and cotton balls. Using what now seems to be relatively crude data, Target’s data analysts were able to pinpoint a delivery date within a few weeks. Initially, women who purchased particular groups of products (oversized bags, moisturizer, vitamins), identified by credit card purchases, were sent coupon books for baby products. However, trouble ensued when an irate father marched his high school aged daughter, coupons in hand showing pictures of maternity dresses, babies, cribs, and diapers, down to Target, “My daughter got this in the mail!” the New York Times Magazine account reported. “She’s still in high school, and you’re sending her coupons for baby clothes and cribs? Are you trying to encourage her to get pregnant?” Several days after apologizing to the father and daughter the Target executive called the family again, only to find out that the algorithm was, in fact, accurate. The teenage daughter was due in August. Target knew about her pregnancy before her father did. It may be seductive to de-emphasize the role of intention here as the information that emerges from these data sets appears to be discovered from randomness; that it is located in hidden patterns and connections across the sheer immensity of the data. Many of the accounts promoting metrics follow the narrative arch of the Target story wherein computer codes magically reveal relationships that point to yet unknown truths.13 Yet, intention is integral to the datasets that are selected, the joins that are  Indeed, the extent to which such work (and similar deployments of artificial intelligence) deprofessionalizes medicine and other fields and produces results without appropriate oversight raises considerable concern but such concerns have not appeared to influence the continuation of such work. On the role of AI in professional relationships, see: Haupt, Claudia E. 2019. Artificial professional advice. Northeastern University School of Law Research Paper No. 350–2019, June 7. SSRN: https://ssrn.com/abstract=3400898. Steven Sutton, Vicky Arnold, and Matthew Holt argue that deploying AI in knowledge work, like medicine, law, and business, may speed up decision making but at the expense of skill development, knowledge acquisition and retention, and human expertise. See, Sutton, Steven, Vicky Arnold, and Matthew Holt. 2018. How much automation is too much? Keeping the human relevant in knowledge work. Journal of Emerging Technologies in Accounting 15: 15–25. https://doi.org/10.2308/jeta-52311 13

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coded, the information selected, and, at a more basic level, the underlying conviction that useful information will be gained from the process. Despite the appearance of random discovery, very little of what is achieved in metrics is accidental.14 The role of intention in metrics is, in fact, doubled. Intention informs both what and how data is collected and which and how behaviors are incentivized. Jerry Muller, in his book, The Tyranny of Metrics shows how, as a belief system, metrics assumes that intention can be quantified and thereby measured. Muller is particularly critical of the use of metrics for performance improvement and various forms of institutional grading. Noting that the quantitative basis of metrics promises an institutional discourse of transparency and objectivity, Muller writes that advocates of metrics use the concept of “accountability” to evoke both the capacity to be counted and responsibility. Performance can then be quantified. Muller writes, “performance is therefore equated with what can be reduced to standardized measurements.”15 The outcome of this emphasis, according to Muller, is a three-fold ideological belief that (1) human judgment and experience can be replaced by standardized data that quantifies performance as a numerical indicator; (2) that publicizing these indices makes people and institutions accountable; and (3) that people are motivated when rewards and punishments are tied to such measurements.16

 Yet, “discovery rhetoric” in metrics remains strong. Accounts have stressed and assumed the integrative power associated with big data’s heuristic tools but researchers have also shown the ready pitfalls, false correlations, and meaningless random associations of variables that can be easily attained by mining through unstructured data and hoping for surprise revelations. University of Toronto Epidemiologist Peter Austin and his colleagues demonstrated that by testing multiple hypothesis across patient data from all 10,674,945 Ontario residents between 18 and 100 years old, they could show that people born under the astrological sign of Leo had a higher probability of gastrointestinal hemorrhage while those born under the sign of Sagittarius had a higher probability of humerus fracture. See, Austin, Peter, Muhammad Mamdani, David Juurlink, and Janet Hux. 2006. Testing multiple statistical hypotheses resulted in spurious associations: a study of astrological signs and health. Journal of Clinical Epidemiology, 59: 964–969. https://doi.org/10.1016/j. jclinepi.2006.01.012. In some of my own early experimental studies, our data showed conclusively that patients with diabetes were more likely to have higher blood sugar levels and patients with lung disease were more likely to have pneumonia. 15  Muller, 17. 16  Muller, 18. 14

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Equating human actions with quantitative measurement forges the perception that intention can be operationalized and incentivized. “Indicators specifically measure the outcomes of the actions taken by administrators, directors, managers, and staff in their day-to-day work,” promotes Steven Berger who writes about hospital financial metrics.17 Such measures, the rhetoric promotes, transparently reveal the results of individual and group actions. As the rhetoric would have it, the process whereby specific metrics are created, refined, coded, and then implemented is a process whereby intention, at the organizational level, is made evident—what gets measured gets done. Bridging macro and micro scales, large-scale intention is articulated by the codes written for each specific metric. Here, intention, as incentivized action, is narrower and more result-oriented than motive (as Anscombe prescribes). The metric accounts (simultaneously proactively and retroactively) for the question “why” in human action.18

 hat Gets Counted: Discharge by 11:00, W a Case Study But articulating metrics as intention also shows the limitations of using heuristics (electronic or otherwise) to account for or incentivize human behavior. For example, take the common hospital metric “discharge by 11:00.” The metric measures the number of patients discharged from medical and surgical floors by 11:00 am. The computer code creating the metric is deliberate and intentional: select from [Table] ..patientID  Berger, xiv.  See Anscombe, p, 87–89. “We can see that a great many of our descriptions events effected by human beings are formally descriptions of executed intentions.” Anscombe writes of “practical” and “speculative” knowledge, “the account that one could give of what one is doing, without adverting to observation; and the account of exactly what is happening at a given moment (say) to the material one is working on” (88–89). Intentional action is informed by a knowledge about what one is attempting to accomplish at that moment, “knowing one’s way about” as Anscombe puts it. Intentional actions are voluntary, reminds Anscombe. Such actions may be “reluctant” but still voluntary. 17 18

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..locationID ..bednumber ..dischargedatetime ..diagnosis ..birthdate ..datediff(yy.dischargedatetime,birthdate) as Age ..attendingphysician where dischargedatetime between (0800 and 1100) and locationID in (“MSU2”, “MSU3”, “MSU4”) The code shows the explicit connection between metrics and intention, from the writer’s deliberate selection and exclusion of relevant data to the sequencing of specific restrictive “where” statements. The metric’s simplicity, objectivity, transparency, and quantifiable rhetoric suggest scientific precision. Metrics are a unique and seductive combination of intent and quantifiable precision. While all this may seem obvious, computers, after all, do what they are told, the metric’s efficiency obscures the machinery in which an algorithm is deployed and the more specific political intent of the measurement. Discharge by 11:00 was established to measure hospital throughput. By 11:00 the first large surgeries of the day are waking up in post-surgical recovery and will require a bed on a medical/surgical floor. At the same time, the emergency room is beginning to get busy and starting to admit particularly sick patients. Every medical/surgical patient that can be discharged by 11:00 am frees up space for surgical and ED admissions. Here is where Muller’s critique is especially relevant. “Most organizations have multiple purposes,” he writes, “and that which is measured and rewarded tends to become the focus of attention, at the expense of other essential goals.”19 While surgeons and emergency department physicians emphasize discharge by 11:00, hospitalists and internal medicine physicians (if they care about metrics at all) emphasize readmissions and post-­ discharge care to claim that a longer hospital stay is in the patient’s best

19

 Muller, 18.

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interest and could prevent a future readmission.20 Thus, the metric privileges the intentions of surgical and emergency physicians to clear beds in their units and enable greater volumes at the expense of other specialists’ concerns, expertise, and outcomes. Physicians also resent this imposition on their professional judgment. “Professionals tend to resent the impositions of goals that may conflict with their vocational ethos and judgment” Muller rightly explains, and the imposition of multiple, often contradictory, metrics creates an equally contradictory, in Muller’s words, “pernicious” work environment.21 As heuristics, metrics short-cut professional judgment, informed decision making, and reduce critical thinking to a simple quantitative measure. As noted above, the heuristic is efficient, but the efficiency comes at the cost of more robust and comprehensive understanding. Worse, the metric narrows vision, obscuring and complicating the originating purpose for the measurement. Dan Shine, the former Chief of Medicine in Colorado, has argued that “[s]tudies of morning hospital discharge come almost entirely from the Emergency Department” and emphasize ED overcrowding.22 He also notes the pernicious work-­ arounds the metric incentivizes. “Under pressure to discharge before noon, caregivers might well be tempted to hold a patient over for next-­ morning departure” thereby undercutting efforts to reduce patient’s length of stay, improve patient throughput, potentially exposing more patients to infection or other nosocomial events. A “full-throated” effort to discharge patients, he writes, would postpose other essential early morning duties, reduce patient satisfaction as patients are rushed off the wards, reduce staff satisfaction, reduce time available for teaching, and

 See for example, Powell, Emilie, Rahul Khare, Arjun Venkatesh, Ben Van Roo, James Adams, and Giles Reinhardt. 2012. The Relationship between inpatient discharge time and emergency department boarding. Journal of Emergency Medicine 42: 186–196. doi: https://doi.org/10.1016/j. jemermed.2010.06.028. Powell et al. conclude that shifting inpatient peak discharges by 4 hours earlier could eliminate ED boarding. 21  Muller, 19. 22  Shine, Dan. 2014. Discharge before noon: An urban legend. The American Journal of Medicine 128: 445–446. doi: https://doi.org/10.1016/j.amjmed.2014.12.011 20

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potentially increase readmissions and complications.23 None of these complications and larger contextual issues is evident in the heuristic for bed management. Similarly, looking back at the metric for hypertension, Bakris and Sorrentino note that there is an efficiency and simplicity to a universally recommended blood-pressure goal. However, they convincingly argue that a single metric for blood pressure is problematic when a number does not consider the underlying cause or a therapeutic range consistent with different disease, age, and activity groups. For example, they note that a diastolic pressure below 60 mm Hg has been linked to ischemic heart disease and progressive kidney diseases among people with diabetes and coronary disease. 24 They also note that asserting the same blood pressure goal for a 30-year-old and an 80-year-old patient is unrealistic. They conclude by advocating for “an individualized” approach to hypertension that is responsive to the underlying cause and an appropriate therapeutic goal. As both examples demonstrate, a fixation on any particular metric without a larger understanding of how the metric is constructed and why the metric is being deployed can easily lead to worse outcomes. Of course, there are practical limitations to metrics as well. Muller helpfully offers what he calls “recurring flaws” that are typically associated with the implementation of metrics. Organizations are likely to measure those data points that are most easily measurable rather than what is useful, important, or even relevant to the problem at hand.25 For example, most educators are now familiar with being evaluated by the number of students taught rather than a measure of student learning and educational outcomes. Assessing what or how much a student learned over the course of a semester is much more difficult to measure and influence.  Shine responds directly to a paper by Wertheimer et al. that argued that discharge before noon actually decreased readmissions. Shine argues that Wertheimer et al.’s study was conducted during an effort to reallocate substantial medical social services to weekends. Shine argues that these other changes to services confound Wertheimer et al.’s findings. Further, Shine notes that Wertheimer et al. assumed but did not measure the effect of pre-noon discharge on ED boarding. See: Wertheimer, Benjamin, Ramon Jacobs, Martha Bailey, Sandy Holstein, Steven Chatfield, Brenda Ohta, Amy Horrocks, and Katherine Hochman. 2014. Discharge before noon: an achievable hospital goal. Journal of Hospital Medicine 9: 210–214. 24  Sine, 3. 25  Muller, 23. 23

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Similarly, it is common to measure simple processes and inputs rather than more complex systems, outputs, or outcomes.

Intention, Factishes, and the Genealogy of Big Data This chapter has attempted to show the ways that metrics—both as investigative method and evaluative incentive—deploy intention as an operational strategy. Working both descriptively and prescriptively, metrics thereby inscribe institutional intentions. However, seeing metrics as a strategy of intention demonstrates how intention becomes prescribed rather than realized when human behavior is reduced to a number. As a heuristic, an expedient way to generate information, the metric can only be a partial and biased understanding. As such, the actions the metric incentivizes are perhaps more interesting as a way to read and reveal power. Investigating what the metric intends to accomplish, like reading the code behind the algorithm, demonstrates the power dynamics that helped to build and establish the metric, the priorities of those who deployed the metric, the social and institutional dynamics those enforcing the metric hope to build, and the way power flows within a social context. Buried within the project of analytics is the ongoing belief that data, wherever it is found, must be meaningful. Such a belief promotes yet another level of intention, one that seems to place greater value in the pragmatics of technique and disciplinary-specific requirements for work. Here, meaning can be retroactively placed onto the metric or the machine learning to demonstrate validity. As such, these practices occur entirely without a theory of (or for) interpretation. The machine-learning component of such work, while admittedly still in early stages, emphasizes the heuristic expediency of the genre. For example, Kabir, Ruiz, Alvarez, and Moonis used machine learning to identify co-morbidities and epidemiological findings associated with outcomes after ischemic stroke.26 The  See: Kabir, Ahmedul, Carolina Ruiz, Sergio Alvarez, and Majaz Moonis. 2018. Regression, classification, and ensemble machine learning approaches to forecasting clinical outcomes in ischemic stroke. In Biomedical engineering systems and technologies. BIOSTEC 2017, ed. Nathalia Peixoto, Margarida Silveira, Hesham Ali, Carlos Maciel, and Egon van den Broek. Communications in Computer and Information Science, vol 881. Springer, Cham. 26

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researchers found that a modified Rankin score (a measure of disability and dependence after a stroke), older age, stroke severity, alcohol use, atrial fibrillation, and hypertension were associated with poorer outcomes after a patient experienced an ischemic stroke. Perfusion treatments and neuro-interventions were associated with improved outcomes. Such findings should be commonsense to a second year medical student and especially to those with expertise in anatomy, physiology, and neuro-pathology and as such, they validate the machine learning algorithm. Here, the purported benefit of the big data project is its validation—that the machine got it right. A machine learning retrospectively and providing quick and efficient results without relying on a comprehensive medical education is held up as a beneficial and progressive outcome. Yet, the reporting intentionally elides the very process and expertise that generated the medical knowledge the computer validated. There is an ironic mysticism at work here that Aristotle would appreciate. Given enough data, the machine will learn shortcuts to diagnoses and outcomes we already know. In the same way, as Aristotle wrote, an algorithm aggregating good birth, plenty of friends, wealth, healthy children, and a happy old age can persuade us that the state of the nation is secure. To conclude this chapter, I would like to turn to a contrast Foucault made between what he called analytics and theory and a proposition to adopt a different sort of analytics than what has been described so far. As Dreyfus and Rabinow describe, Foucault’s concept of analytics is a specific description of the “micropractices” that form day-to-day activities, relationships, and institutions. A study of micropractices is a study of power, “from the bottom up.”27 As Dreyfus and Rabinow note, Foucault saw power relations as “intentional and non-subjective” and “their intelligibility derives from this intentionality.”28 That, in the time since Foucault was writing, the instruments for such intentionality have shifted toward computer algorithms and an acquiescence to red, yellow, and green stop lights on digital dashboards seems to only validate his insights and methods for understanding the reciprocal and reinforcing ways actors  Dreyfus, Herbert L. and Paul Rabinow, 1983. Michel Foucault: Beyond structuralism and hermeneutics. Chicago: University of Chicago Press, 123. 28  Dreyfus and Rabinow, 187. 27

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achieve political ends. The ways to talk about intentionality then, according to Dreyfus and Rabinow, require us to examine everyday practices themselves and the technologies that would regulate and incentivize these practices. Such an examination can be both retroactively critical and what I would like to call self-consciously analytic. As a retroactively critical reading of intention in analytics, something we could call a hermeneutics of big data, would, as Bruno Latour proposes, recognize the iterations between fact and fetish. A hermeneutics of big data would realize the amount of human work that is required to assemble sufficient facts to transform practices-as-metrics into autonomous and seemingly objective truths.29 Latour uses the term factish to suggest an alternative way to consider such truths. As such, we can consider the potential of the factish representation discharge by 11:00, and evaluate the implication and intention constructed within its manifestation and deployment. Similar work would examine the factish work accomplished by metrics like readmissions, student enrollment, crime statistics, blood pressures, and other seemingly factual concepts intended to motivate human action. Foucault posited such work as decipherment, what Dreyfus and Rabinow describe as seeking to “analyze exactly what these practices are doing.”30 Such a project would examine the codes (the factishes) of analytics in an effort to better understand how and why the metrics endeavor to make us what we are (or what we are becoming). The point here, following Dreyfus and Rabinow, is not to “add more discourse” but instead, “to find the rules which determined or controlled the discourse….”31 The rules would include things like computer code, excel syntax, and machine learning algorithms and making them transparent would do the important work of demystifying analytics by showing how the code accomplished exactly what it was intended to produce. Foucault argued that such a project would abandon hermeneutics since there is no true or deeper meaning behind the analysis, no liberating finding embedded  Bruno Latour, 2010. On the Modern Cult of the Factish Gods. Durham, NC and London: Duke University Press. 30  Dreyfus and Rabinow, 185. 31  Dreyfus and Rabinow, 123. 29

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within the code, only more code which the programmers find significant.32 Stepping away from the metric demonstrates the extent to which the metric holds value only for those who are subject to its rule-­governance and ontological transformations. Dreyfus and Rabinow write that such a project would ask, “How…do the discursive practices [metrics] viewed as meaningless events in a purely logical space form and govern speakers and the statements, subjects, and objects, they take to be meaningful?”33 In other words, to use the language of this book, how do the intentions informing metrics transform significance into meaning?

Toward Practice A continued concern throughout this book has been how to generate a more proactive project for the humanities. Given all of the limitations associated with analytics an easy argument would be to simply abandon the field. Analytics cuts too close to expediency for serious insights into human behavior. Machine learning may simply be telling us what we already know. At the same time, quantification provides a language for summarizing large amounts of data and enables researchers to expand beyond relatively small numbers and research sites. For example, I teach a humanities seminar that asks students to use tools from analytics and data science to examine questions we consider pertinent to the humanities. What we mean by this is that the projects attempt to bring quantitative analysis to topics like social justice, identity, social disparities, aesthetics, persuasion, and human motivation. Broadly scoped, the projects attempt to use the tools from data science to help us better understand the human experience and what differentiates events and activities as uniquely human.34

 Dreyfus and Rabinow, 79.  Dreyfus and Rabinow, 79. 34  Using quantitative models in the humanities is not new. Springer publishers for example has managed a book series, Quantitative methods in the Humanities and Social Sciences since 2014 (see, https:// link.springer.com/search?facet-series=%2211748%22&facet-content-­type=%22Book%22). Where we have differentiated our approach has been in the types of questions we are pursuing and the application of our work. Rather than seeing our work contributing to various projects within a particular humanities-based disciplinary perspective we proposed taking concerns normally raised by humanists and positing these in an applied, extra-disciplinary context. 32 33

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Two students, Nirali Parekh and Kelsey Krupp, both undergraduate life sciences majors, completed projects that have stayed with me as productive models. Neither project was naïve in the sense that either student posited that the work was comprehensive or definitive. What we found instead was that the data science evoked useful and important questions. In this way, as a proactive (productive) strategy, the analytics did act as heuristics, as shortcuts to topics, but as self-conscious analytics we saw the projects as opening new topics that would then require further (and often multi-disciplinary) examination. For example, Parekh used data sets from the World Bank, the OECD, and the online data repository Gapminder to examine what she termed “resiliency” of seven South and South-East Asian countries: Bangladesh, India, Indonesia, Malaysia, Myanmar, Sri Lanka, and Thailand.35 She examined malaria rates and GDP for each country the year before each country was hit by a major earthquake or tsunami and for the five years after the natural disaster. She defined resiliency as the years needed for a country’s economy and malaria rates to rebound to the pre-disaster state after the natural disaster. She wanted to examine which countries rebounded the fastest after a disaster and what social factors appeared to set that country apart from its peers. After establishing which countries appeared more and less resilient after a natural disaster, Parekh evaluated societal metrics across the seven countries to examine which metrics were more associated with economic resiliency. Her analysis documented that the number of women owned businesses and the number of women employed in business (not agriculture) were positively associated with economic resilience. Countries with a higher proportion of women in the workforce (Indonesia, Bangladesh) rebounded from a natural disaster faster than those countries with lower rates of women’s employment. The percent of women in government was not associated with resilience, nor did the amount of infrastructure spending lead to a faster recovery. Literacy rates and the size of the  For data sources, see: World Bank. Countries and Economies. http://data.worldbank.org/country. Accessed 1 Jan 2020; Organization for Economic Co-operation and Development (OECD). Economic Outlook for Southeast Asia, China and India 2014 Beyond The Middle-Income Trap, OECD iLibrary. for http://www.oecd.org/site/seao/Pocket%20Edition%20SAEO2014.pdf. Accessed 1 Jan 2020. Gapminder data is available online at www.Gapminder.org 35

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population (lower population countries rebounded faster) were also associated with greater resilience. Kelsey Krupp, an undergraduate student in the same seminar, investigated the incidence of cancer clinical trials by the type of cancer studied. She gathered clinical trial data, cancer incidence data, and cancer mortality data from the National Cancer Institute and the National Library of Medicine website ClinicalTrial.gov. She localized her study to ten states: Texas, New York, California, Massachusetts, Illinois, Pennsylvania, Maryland, Florida, Connecticut, and North Carolina. She focused on cancers of the breast, lung, skin, and liver. She reported mortality rates for each cancer from 1976–2011 and the number of clinical trials from 1995–2005.36 She then used data from the New York State Cancer registry to complete a focused study on New York breast and liver cancer survival rates.37 To summarize her data, Krupp created a ratio from cancer incidences and deaths in a particular year (for the purpose of her project she chose 2010). She then compared her living:death ratio against the number of clinical trial for each cancer. Krupp’s hypothesis was that all types of cancer would have similar numbers of clinical trials and receive relatively equal funding. Her second hypothesis was that any differences in the number of studies or funding for any particular type of cancer could be explained by a higher mortality rate for that type of cancer. In other words, higher mortality cancers would drive more studies and funding for that disease. She found that the number of clinical trials was inversely correlated to the living:death ratio. In other words, cancers with higher survivability had more clinical trials. Initially, she thought that perhaps she was seeing the result of scientific progress, more clinical trials led to increased  Four criteria needed to be met for a clinical trial to be included in the study: The trial had to be completed, have results, be an interventional study, and be a study on drugs. 37  For data sources, see: US Department of Health and Human Services, National Cancer Institute. Comprehensive Cancer Information. http://www.cancer.gov/. Accessed 1 Jan 2020. U.S. National Library of Medicine. Search for Studies (database). http://www.clinicaltrials.gov/ct2/home. Accessed 30 April 2014; WebMD. Liver Cancer Causes, Survival Rate, Tumor Types, and More. http://www.webmd.com/cancer/understanding-liver-cancer-basic-information. 1 May 2014; New York State Department of Health. NYS Cancer Registry and Cancer Statistics. NYS Cancer Registry. http://www.health.ny.gov/statistics/cancer/registry/. April 30, 2014. 36

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survivability. While this may be a partial explanation, her data from New York State suggested a different narrative. Krupp found that while New York State breast cancer deaths had declined from 1976–2011 (slope = −34.5) deaths from liver cancer had significantly increased over the same time (slope = 21.3). While there were 28 clinical trials for breast cancer from 1995–2005, there were 2 clinical studies listed for liver cancer. Both students recognized the limitations of their studies and knew that what they could discover and present in one course was limited. Parekh, a scientist and an international student from South-East Asia, was intrigued to find that gender equality had measurable consequences for a country’s economy. She came away with a new appreciation for her own education and future career and she emerged from the project as an advocate for women’s education and employment. Krupp was disturbed to conclude that her hypothesis—that resources would objectively shift to address disease burdens—could be incorrect. In her conclusion, Krupp noted that liver cancer is potentially a stigmatized cancer, as it has been associated with alcohol abuse and hepatitis. She wondered then if cancer funding may be more subjective and that cancers “one gets by chance rather than because of a dangerous lifestyle” receive more funding, scientific interest, and advocacy. Yet, she noted, simply because some people may contract liver cancer because of alcohol abuse, others suffer from the same disease because of genetics or chance. How one contracts a disease should not influence whether or not that disease receives scientific attention, she concluded. Five years after Krupp’s project, Suneel Kamath, Sheetal Kircher, and Al Benson, all from Northwestern University in Chicago, completed a similar study.38 The researchers examined oncology nonprofit organizations (NPO) that raised money for cancer research. Using data from 2017–2018, they compared total revenue from each NPO supporting a cancer type with the incidence, mortality, person-years lost of the cancer supported. The researchers also created a metric. In this case, their metric quantified the extent to which a disease was associated with a stigmatized  See, Kamath, Suneel, Sheetal Kircher, and Al Benson. 2019. Comparison of cancer burden and nonprofit organization funding reveals disparities in funding across cancer types. Journal of the National Comprehensive Cancer Network. 17: 849–854. doi: https://doi.org/10.6004/ jnccn.2018.7280 38

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behavior. Their results were similar to those found by Krupp. Cancers associated with a stigmatized behavior are poorly funded. The researchers wrote, “NPO funding by cancer type is not proportionate with individual cancer burden on society. Disease stigma negatively impacts funding. A significant need exists to increase awareness and funding for many under supported but common and highly lethal cancers.”39 Returning to Rabinow’s accusation presented in the Chap. 1, that many humanists are using “the wrong tools for the wrong job,” I would like to position studies like those conducted by Parekh, Krupp, and Kamath, Kircher and Benson as efforts toward more appropriate tools to tackle more influential jobs. The projects are concerned about the human experience and are based in a recognition that human perception, bias, and behavior cannot be separated from systems, technology, and decision making. Their job is to demonstrate which human factors influence problems, how and why the influence is occurring, and the effect of that influence on the underlying activity. Their most recognizable tools are statistical and quantitative; but, all three projects deploy tools forged in humanistic debates: concerns about justice, equality, what we mean by a “good life,” how we describe and account for the human burdens associated with natural disasters and disease, and how we justify the distribution of goods in scarce economies. This chapter has posited that in both critique and in practical deployment analytics and the formation of metrics provide the humanities with opportunities to experiment with their own heuristics of intention. These experiments require new tools, new approaches, and new relationships as we move to address more granular and complex problems. As we saw previously in Chap. 4’s discussion of an “intentional humanism,” recognizing a cancerous tumor is only a part of what is a much larger project. What to do with that finding, productively transitioning from significance to meaning, necessitates an enormous amount of integration between the natural, the human, and the technological sciences. In order for such integration to occur, we need to recognize that such projects require extraordinarily difficult multidisciplinary approaches and efforts and a certain amount of extra-disciplinary knowledge among 39

 Suneel et al., 849.

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textual scholars hoping to work with colleagues in more technical departments. While accurate, it is too easy for humanists to argue that technological and natural scientists need to become more willing to venture into the “whys” of human problems in addition to the whats and hows. Scholars in textual studies need to be willing to expand their scope of study beyond texts and artifacts and their methods beyond retrospective critique. We need to be more willing to undertake formal studies in technical disciplines, to encourage (require?) our students to take a second major or a minor in a science or engineering discipline, and, like many scholars in applied scientific disciplines, to integrate forms of clinical practice (not necessarily medical) into our job descriptions. “Analytics” write Dreyfus and Rabinow, “respects established problems and concepts, recognizing that they are concerned with something important; it does so in a way that reveals more about society and its practices than about ultimate reality.”40 Perhaps these can be some of the new tools we can use for tackling more relevant problems.

 Dreyfus & Rabinow, 204.

40

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Lynley wondered what he saw there, what anyone saw when they tried to interpret someone else’s intentions. Elizabeth George, Just One Evil Act (George, Elizabeth. 2016. Just One Evil Act. New York: Penguin Books, 450)

It is 11:30 pm and my crew has been called to the home of a 92-year-old patient who is suffering from terminal cancer. When we arrive we find our patient in the throes of continuous vomiting which has now become dry heaving. Exhausted, in terrible pain, and shrunken with weight loss my patient is obviously very sick. Our pre-hospital protocols here are pretty straightforward: assess the patient’s vital signs, check blood sugar levels, provide supplemental oxygen if needed, do serial EKGs to assess and monitor for cardiac problems, start an IV, give the patient intravenous fluids to treat dehydration, provide sugar if needed, give an antiemetic for nausea and vomiting, and provide an appropriate medication for pain. The hospital will provide advance diagnostics, nutrition, electrolytes, further pain control, treat any wounds and infections, consult with the patient’s oncologist and primary care provider, and, after several days,

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my patient will probably return home. But as my partner wheels our stretcher up the ramp to the house, the patient’s spouse and daughter are insistent, he does not want to go to the hospital. I turn to him and he looks up at me and shakes his head, he’s not going anywhere. He is mentally competent, he speaks clearly and presents a clear and consistent argument. He knows he is sick, he knows he is dying, he’s been back-and-­ forth to the hospital dozens of times in the past few months, he knows there is nothing life-extending medicine can offer him at this point. He wants to die at home. The pre-hospital protocols we use in EMS are mini-genres designed to guide us through most of the medical conditions we treat. Like genres, they enact and direct social action as they detail procedures for everything from scene safety, to how to interact with our patients, to what procedures and medications we should be giving scaled by level of care. As genres, the protocols are disinterested to intention, to my intention as a provider, and intentions the patient may have. The protocols assume that patients want to be treated, want to get better, and want to go on living their lives. This is no small assumption. As Anne-Cathrine Naess, Reidun Foerde, and Petter Andreas Steen have explained, “In clinical practice most decisions are made on premises with a variable degree of uncertainty, with less than ideal amounts of information about the patient and his/her true wishes and about the medical prognosis.”1 In emergency medicine there is rarely an existing or meaningful clinician-­ patient relationship and the usual tenets of autonomy: a fully informed and competent patient who understands medical information and the consequences of choosing different options, who can make decisions free from external pressures, and who consistently makes the same choices given similar circumstances are also rare.2 If a patient wishes to make an autonomous decision to refuse treatment, that process has its own generic process. The patient must complete a document attesting that he or she  Naess, Anne-Catherine, Reidun Foerde, and Petter Andreas Steen. 2001. Patient autonomy and emergency medicine. Medicine Health Care and Philosophy 4: 71–77. 2  Naess et al., 72. Naess, Foerde, and Steen note that these four conditions for patient autonomy are “not always the case.” They note that a patient can make “an autonomous decision not to make an informed decision and ask to be guided by the professional.” Here, the usual paternalistic model shifts the burden of decision making onto the clinician. 1

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is mentally competent, refuses recommended care and transport, and will not hold the pre-hospital team legally responsible for any medical outcomes attributed to the refusal of care. I have found my time in EMS alternatively refreshing, challenging, rewarding, and terrifying. Refreshing in that these practical, results-­ oriented, vital events are very much apart from grand metaphors and ceaseless critique that occupy most of my academic life. Challenging in that fieldwork is equally clinical and practice, requiring skills and knowledge that must be continually practiced, reinforced, and refreshed. Successfully diagnosing, treating, and transporting a critically ill patient to definitive care and seeing that patient improve and do well is phenomenally rewarding. Yet, as Jesse Wackerbarth, a third-year medical student writing about his first medical rotations in internal medicine puts it, “medicine plays for keeps” and realizing this fact is terrifying.3 Critically ill patients do not get do-overs, extensions, or excuses. Seemingly procedural tasks like starting an IV, calculating a drip, placing an ET tube, or accessing a vein for phlebotomy become sources of deep anxiety when not performed regularly. Siddhartha Mukherjee, reflecting on his own medical education writes that while on the surface medicine appears solid, factual, and precise, his learning really began when he realized that medicine deals with data that is “imperfect, incomplete, or uncertain.”4 While learning medical knowledge is its own challenge, what was more difficult for Mukherjee (and for me in my much more limited way) was learning how to apply this knowledge to practice. Murkherjee writes, “But all this information could, I soon realized, be looked up in a book or found by a single click on the Web. The information that was missing was what to do with information….”5 “The laws of medicine,” he now relates to his residents, “are really laws of uncertainty, imprecision, and incompleteness. They apply

3  Wackerbarth, Jesse. 2020. The performance art of student doctoring. New England Journal of Medicine 382: 6–7. 4  Mukherjee, Siddartha. 2015. The laws of medicine: Field notes from an uncertain science: New York: TED Books, Simon & Schuster, 5. 5  Mukherjee, 5.

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equally to all disciplines of knowledge where these forces come into play. They are laws of imperfection.”6 These laws of imperfection were what we encountered with our patient now refusing to go to the hospital. Protocols, like genres, work best in relatively stable, conventional situations. When the way forward is knowable and predictable these forms provide utilitarian guidance for both amateur and expert. It is not that genres cannot deal with uncertainty. There are generic ways for dealing with a sick patient who refuses transport, we could have simply had the patient sign a refusal form and gone on our way. We could have sought a physician’s order to forcibly take him to the hospital against his will. But leaving a patient vomiting, dehydrated, and in severe pain alone at home would have been irresponsible and forcing him against his will to go to the hospital would have been unethical and possibly illegal.7 The usual approach here would involve a home visitation from a hospice nurse. But the family had not set up any home care and at this hour, in these conditions, handing my patient off was not an option. We tried again to convince him to go to the hospital, explaining that hospice care could be arranged at the hospital, in person, when he would be discharged and would, we hoped, prevent a similar situation from happening again. Running short on options, I finally called the emergency department at my hospital and asked to speak to the attending physician. I relayed our situation, described my patient, his vitals, his vomiting and pain, and his refusal to go to the hospital. After a short pause the physician asked me “well, what do you want to do?”  Mukherjee, 7.  The situation does bring up the question of patient competence. Can a patient who is obviously sick but refuses care be considered competent? Working from Buchanan (1986), Naess, Foerde, and Steen write that “a major problem is to define how well the patient must be able to reason about a decision in order to be competent to make it” (73), see Buchanan, A. 1986. The question of competence. In Ethics in Emergency Medicine, ed. Kenneth Iserson, Arthur Sanders, D.R. Mathieu, and Allen Buchanan, 52–56. Baltimore, London: Williams and Wilkins, 52–56). The case I review above is very much like the case presented by Naess, Foerde, and Steen who also discuss a patient who refused treatment. Their patient case, like mine, described a patient who had very good reasons for staying at home, who communicated these reasons very clearly, “whose judgement and insight appeared sound,” and who “displayed no disorientation and her answers gave no signs of confusion or denial of the disease” (73). In both cases, the patient was deemed competent and able to make important decisions about treatment. 6 7

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Timothy Quill and Howard Brody, both physicians, have described a shift in American medical care from paternalism, an approach in which medical decisions were exclusive to physicians, to full patient autonomy, in which physicians merely inform patients about different medical options and then back away to let those patients make independent choices.8 Quill and Brody acknowledge that paternalism denied patients the right to participate in their own medical decisions and was too often subject to gender, racial, and socioeconomic bias. But, they also argue that by fully embracing patient choice, “physicians fail to use their power appropriately” because they are inappropriately “withhold[ing] their guidance” in a critical moment for a patient and the patient’s family.9 “Patients,” they write, are then left to “navigate treacherous medical terrain without adequate medical guidance.”10 As an alternative, Quill and Brody propose what they call an “enhanced autonomy” model. They argue that “autonomous medical choices are usually enhanced rather than undermined by the input and support of a well-informed physician.”11 “Enhancing patient autonomy,” they write, “requires that the physician engage in open dialogue, inform patients about therapeutic possibilities and their odds for success, explore both the patient’s values and their own, and then offer recommendations that consider both sets of values and experiences.”12 The model is “relationship-­ centered” they note rather than “exclusively patient-centered” as it allows both the patient and the physician to articulate their biases, their perspectives, their judgment, and perhaps most importantly, their intentions in the context of medical decision making.13 Orienting the concept of “personalized medicine” in a slightly different direction, they write, “to use medicine’s power in a personalized way, physicians must become expert not only in the science of clinical medicine but also at learning about  Quill, Timothy and Howard Brody. 1996. Physician Recommendations and Patient Autonomy Finding a Balance between Physician Power and Patient Choice. Annals of Internal Medicine 125: 763–769. 9  Quill and Brody, 764. 10  Quill and Brody, 765. 11  Quill and Brody, 765. 12  Quill and Brody, 765. 13  Quill and Brody 765. 8

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patients as unique human beings with life histories and values that must be used to guide treatment.”14 Speaking with my medical director by phone, I suggested we treat the patient at home and have hospice care contact the family as soon as possible the next day. We worked out appropriate doses for controlling my patient’s pain and nausea and the physician said he would leave a note for a hospice coordinator to contact the family in the morning. After administering the medication, we took a final set of vitals, made sure the patient and family were comfortable, completed the necessary documentation, and went back to our station. While, in retrospect, the decision to treat our patient at home seems obvious, the activity required a deliberate step out of routine (permissible) genres and a temporary aggregation of something new. This new aggregation combined several different activities, pre-hospital, home health, and hospice care, with legal and ethical obligations, while recognizing and allowing intention (mine, my patient’s, the family’s, the physician’s) to influence our way forward. Genre, typified responses to recurring situations, breaks down when professional judgment is required to negotiate a unique and dynamic situation. Intention becomes heightened and important in such dynamic situations and perhaps crucial. Before deciding on a medical course, it is crucial to know (if possible) what the patient’s intention is for treatment and long-term care. Clinical providers (physician, nurse, paramedic, therapist) must also be cognizant and transparent about their own intentions and what they hope to accomplish in this and future encounters with the patient.

 hapter Summary: Curating Intention C in Practice and Purpose As the autobiography in Chap. 1 discussed, this project began with a series of frustrations; with an ongoing sense that my academic orientation had backed me into a sort of epistemological corner of critique, after-the-fact rumination, and reactive scholarship. I was concerned that this training, the impulse to be reactive and descriptive, also had seeped  Quill and Brody, 766.

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into other aspects of my life. Thus became the project to curate a more intentional and proactive space for research and daily living. Now, nearly a decade into this project I found myself backed into a corner again. What I wanted to do, relieve my patient’s pain, stop his vomiting, help him rest, was at odds with what my protocols and position allowed me to do. Here, nearing midnight, in a snowy, cold cabin, in the middle of nowhere in Northern New York intention and genre collide again. Chapter 2 introduced a layered set of implications related to eliding and potentially readopting intention as a formative concept: in the intentions that are enacted by texts; in the intentions that motivated that specific text’s production; and in the relationship between these two forms of intention. Studies investigating intention as a discursive formation would enrich what we know about relationships between discourse and action, persuasion, and resistance. As the chapter discussed, since intention is an aggregation of voluntary (or reluctant) actions with discourses that apply the question “why?” to those actions (Anscombe), studying intention requires an analysis of more than discursive features. Paraphrasing Martin, there is no X-File here, no syntactic or pragmatic feature that will cleverly unpack and reveal a person’s intention. Intention is situated, contextual, non-iterative, and deployed to achieve something. Engaging with intention as a subject of critical study will also insert the concept as a productive component within textual scholarship. This was discussed in Chap. 4 where we saw that humanities researchers were more reluctant to be overt about their own intention, about why they were pursuing a topic and what they hoped would be gained and achieved by their analysis than their colleagues in science, engineering, and business. Naturalizing the intent of scholarly work narrows its influence to the few readers who can unpack the disciplinary assumptions and historical legacies relevant to the problem under study. As persuasion is most often an act of affinity, in other words, people are more likely to be persuaded by social contact than expertise, this narrowing excludes a wider audience and generates suspicion and distrust among those elided from the discourse. The consequences, as we experienced during the COVID-19 pandemic, are tragic and devastating. Perhaps becoming more overt about what we hope textual scholarship will accomplish will help us rebuild some of the trust the humanities has lost in public discourse and

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extend our work with greater relevance for complex societal problems. A discourse of intention would help to better align our scholarship with problem-solving projects in other fields and help us build productive collaborations with experts in those fields. Lastly, as Martin showed in his complaint that free writing advocates had co-opted the discourse of post-structuralism to advocate for their own biases in literacy education, the relationship between these layers, the analysis, and the reason for the analysis matter as they introduce accountability and consistency of purpose to both levels of work. While institutional and career incentives in academia reward publication, grant funding, creative projects, and presentations as metrics (significance), studies of intention that are designed for  and transparent in their own intention become tethered to outcomes, to the people their projects interface with, and to the problems their work attempts to solve (meaning). In this concluding chapter, I introduce the concept rhetorical curations (curations) as strategic, temporary, and situation-specific aggregations of discourse, structure, and intention. As noted below, this rhetorical intent is in isolation from, without influence on, and could even be discordant to, the discursive, genre-based, or social exigencies of the curation’s constituent parts. Curations are temporary and situation-specific. Their deployment is contextual and designed to exploit a particular moment or opportunity. Lastly, curations are aggregations. These are strategic assemblages of constitutive parts (forms, genres, utterances) that are then deployed as a performance rather than to achieve semantic meaning. As noted above, what differentiates curations from other strategic discourse formations is that the semantic consequence of their aggregated discourses is ambivalent to (and often discordant from) the curation’s intended purpose. Returning to Bitzer’s discussion of rhetorical situation and Burke’s dismissal of directed intention, curations could be seen as a sort of concession. I admire Bitzer and Burke’s ability to decertify contrived exigence, spurious situations, fantasy, fiction, and outright hypocrisy. At the same time, I am not sure that such dismissals, while perhaps academically accurate, have been useful, effective, or allowed us to better engage with people who do not share our perspective. Curations are neutral on this point. As a tool for understanding, like decipherment, to examine a

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curation is to examine what was aggregated to enact (a particular) intention and why such an aggregation was productive in that situation. Whereas actors routinely use and adopt genres, which pre-exist the rhetorical situation, as a productive tool, curations are assembled temporarily and proactively to achieve work in a particular situation. Thus, in the case study that opened this chapter, my team eventually enacted a solution by curating several discursive formations into a new and temporary (for us) practice. This was not a routine or typified response. Nor was the response stabilized by structural, historic, or naturalized precedent. At the same time, our actions were not repeatable but were made possible by multiple existing and constituting discourses. We temporarily aggregated discourses from hospice care, nursing, social work, and prehospital care to form our actions and while we respected (and promoted) those practices, we used them strategically. In the future, our EMS agency may become a normalized component of home care and if we continued to provide palliative care for other patients our work might eventually be normalized into discreet protocols (genres).15 But for now, we temporarily aggregated existing discursive formations into a formalized structure that achieved our (and other’s) intentions. Ethically, the curation is guided by intention and what the actor hopes to achieve in a particular situation. This is not to claim that all curations are equally ethical or that a curated end justifies the means. The point here is that unlike genre, which obscures intention, curations put intention back on the table. Above, I suggest that our work “might” eventually coalesce into genre. Yet, that assumption can be challenged. In a 2021 New Yorker music review, Amanda Petrusich discussed a contemporary discontent with the  Community paramedicine has emerged in a handful of jurisdictions in the United States and Canada over the last 5 years as a regularized and official way for EMS to provide home care. See for examples: Lezzoni, Lisa, Stephen Dorner, and Toyin Ajayi. 2016. Community paramedicine— Addressing questions as programs expand. New England Journal of Medicine 374: 1107–1109; Chan, Joyce, Lauren Griffith, Andrew Costa, Matthew Leyenaar and Gina Agarwal. 2019. Community paramedicine: A systematic review of program descriptions and training. Canadian Journal of Emergency Medicine 21: 749–761; Minnesota Department of Health. Community paramedics. https://www.health.state.mn.us/facilities/ruralhealth/emerging/cp/index.html. Accessed 23 Jan 2020. Lucas, Guy. 2020. NC County Approves Community Paramedicine Program after Jump in 911 Calls. https://www.ems1.com/community-paramedicine/articles/nc-county-­ approves-community-paramedicine-program-after-jump-in-911-calls-WXZx58Sh9qaEA8XW/. Accessed 23 Jan 2020. 15

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concept of genre in the music industry. “[G]enre feels increasingly irrelevant to the way we think about, create, and consume art” writes Petrusich.16 The concept of genre, Petrusich elaborates, is tied up in not just technical constituents (instruments, chords, beats, lyrics, and styles in music) but also social and ideological components. “In the earliest days of the recording industry” Petrusich explains, “genre was frequently determined by race, and more than a century later the repercussions of that choice— who gets to make what kind of song—are still profoundly felt.”17 Thus Black artists were sold to Black consumers and white artists to white buyers. Petrusich gives the example of Lil Nas X, whose genre blurring song “Old Town Road” was pulled from the Billboard country chart despite its obvious adherence to country style and the fact that Lil Nas X released it as a country track.18 Genre is important to commerce and to marketing in music but also in film, literature, and other creative works. But the concept seems to have less relevance for the creative process itself and Petrusich notes that with the advent of internet-based music streaming services genre appears to be losing its commercial viability. “Editorial playlists are curated by Spotify employees” Petrusich explains, and many are “fundamentally experiential (‘Songs to Sing in the Car,’ ‘Mood Buster’), and rely explicitly on a presumed listener response.” Describing several curated music lists, Petrusich describes both the mendacity and the richness of a post-­ genre music world. “Tempo aside, it was hard to locate a musical or even an aesthetic commonality here” she writes, “but it was not especially difficult to imagine the kind of listener who might appreciate both songs: young, cool, curious, perhaps roaming an obscure corner of the city with a pair of expensive headphones and a pocketful of half-nibbled weed gummies.”19 “Genre is a reductive, old-fashioned and inherently problematic idea” Petrusich concludes, “and we should all be eager to see it  Petrusich, Amanda. 2021. Genre is Disappearing. What Comes Next? New Yorker. March 8: 68–72. https://www.newyorker.com/magazine/2021/03/15/genre-is-disappearing-what-comes-­­ next, 68. 17  Petrusich, 70. 18  Petrusich, 71. 19  Petrusich, 72.

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rendered moot, but I remain curious about the contours of a post-genre world—what might open up for the future, and what might be sacrificed.”20 The discursive aggregation that is constitutive of rhetorical curations has elements of what Chouliaraki and Fairclough have called “hybridity” which, they write, is a component of all language used toward a social end.21 Hybrid texts, they claim, mix multiple different discourses from unique and separate purposes, creating what they call “anonymous practices” which are “articulated together in new ways to project particular identities and differences.”22 Changing and destabilizing circumstances provide new opportunities for such hybridization and Chouliaraki and Fairclough argue that as the regimented lines between social fields diminish (a characteristic they attribute to “late modernity”) the potential for new aggregations increases. “How the potential for articulatory change within a particular social field is taken up depends on how social subjects act within a field” Chouliaraki and Fairclough write.23 Preferring the terms “agent” and “agency” to intention, they argue, “We might say that people are active— agents—to the extent that they are capable of pursuing collective or individual strategies in their discourse.” Social power (agency) in hybridized discourses emerges from the ability to pull a particularly powerful discourse (law, medicine, cultural status) into a hybrid mix. That mix is then deployed in another situation. Of concern for Chouliaraki and Fairclough is the ability of hybridized texts to operate anonymously and without accountability as “disembedded language practices increasingly flow across linguistic and cultural boundaries, but are assembled in distinctive hybridizations which contribute to the reconstitution of separate identities of space.”24 Chouliaraki and Fairclough describe hybridity as a process of formalization and transformation in which “genre appropriates and  Petrusich, 72.  Chouliaraki, Lilie and Norman Fairclough. 1999. Discourse in Late Modernity: Rethinking Critical Discourse Analysis. Edinburgh: Edinburgh University Press, 13. 22  Chouliaraki and Fairclough, 13. 23  Chouliaraki and Fairclough, 14. 24  Chouliaraki and Fairclough, 83. 20 21

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recontextualizes [other genres and discourses] in normative and transformative ways.”25 For Chouliaraki and Fairclough, genres force discourses toward stability, formalization, and naturalization. Genres encode (embed) ideology. Dominant ideologies are then passed through and normalized in the reconstituted hybrid discourse. Citing an interview with Ehren Pflugfelder, Petrusich writes, “The most identifiable and significant features of a genre are always identified after they’ve actually occurred. . .[a]nyone enthusiastic for the strict adherence to something called genre is engaging in something fundamentally conservative.”26 While there is nothing inherently wrong with conservative impulses, by reintroducing intention we can ask what these impulses hope to preserve and to what extent they will attempt to restrict other productions, creations, and innovations. Whereas Chouliaraki and Fairlcough discount intention as something normalized by genre, Martin offered that understanding the intention of the text helps to account for discursive hybridity and thereby resolves tensions among the different discourses. Writing about efforts to have students revise historical reports as first-person narratives, Martin argues that “to succeed in this task, they have to realize that the story they tell must not only be accurate in historical detail, but ought as well to symbolize and focus attention on issues the historian considers significant.” Such efforts, he writes, “represent an excursion of English discipline discourse across the curriculum” and the task “has to be read not as an opportunity to depart from history discourse, but as an opportunity to use a story to stand for historical interpretation.”27 In both Chouliaraki and Fairclough’s and Martin’s frameworks for addressing hybridization the aggregating discourses retain (some) of their  Chouliaraki and Fairclough, 147. Martin’s discussion involves an educational text that combines narrative with scientific reporting. He writes that “it is the tension between levels (between genre and register in this instance) that construes the meaning.” In the case of the changing report genre (which includes components of personal narrative) Martin sees an educational and cultural change which is then mediated through the new textual practice and accompanying tension in the students’ work. See 32–35  in Martin, James R. 1997. Analyzing genre: functional parameters. In Genre and Institutions: Social Processes in the Workplace and School, ed. Frances Christie and J.R. Martin, 3–39. London: Continuum. 26  Petrusich, 72. 27  Martin, 33. 25

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legacy meaning, significance, and consequence. While the new discursive formation may emphasize or privilege one discourse over others, the resulting discourse retains a component of semantic force from each of its constituent parts. The transformed discourse is important here for its effect on both the legacy and the emerging discourses. Thus, a hybrid discourse constituting a corporate university has influence on both university practices and the colonization of corporate values into new institutional sectors. Unlike hybridity or interdiscursivity, the curation does not hold, transform, or influence its legacy meanings. The curation is ambivalent to the semantic legacy of its aggregated discourses. A curation is aggregated largely for strategic purpose. In developing a curation, agents may appropriate discourses ideologically opposed to their professed values (and purpose) if those discourses, in aggregate, and redeployed in a different situation, could promote the agent’s strategic intent. Or, as in the case above, agents may use sympathetic and mutually supporting discourses but again, these are used primarily for strategic purposes rather than for their informational currency. In what follows, we review several examples of rhetorical curations and consider the characteristics of these aggregations and their relationship to professional discourses.

TRAP Laws and Protecting Women’s Health Writing in The Yale Law journal in 2016, Linda Greenhouse and Reva Siegel describe new attempts by legislatures in South Carolina, Wisconsin, Alabama, Mississippi, Texas, and Louisiana to restrict access to abortion by invoking concerns about women’s health and safety. As Greenhouse and Siegel write, these legislative efforts (often called TRAP laws—targeted restriction of abortion providers) require “that doctors who perform abortions have admitting privileges at nearby hospitals or require that abortion clinics be outfitted as ‘ambulatory surgical centers’” which would be cost-prohibitive.28 In establishing these new regulations, 28  Greenhouse, Linda. and Riva Siegel. 2016. Casey and the Clinic Closings: When “Protecting Health” Obstructs Choice. The Yale Law Journal 125: 1428–1480, 1430.

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Greenhouse and Siegel argue, “[t]hese new laws single out abortion for burdensome, health-justified restrictions not imposed on other medical procedures of similar risk” and “[a]s legislators know or suspect, these requirements are unattainable for many abortion providers.”29 The result of these new legislative activities would be the closure of abortion clinics including, Greenhouse and Siegel predict, “three-fourths” of the clinics in Texas, and two of the remaining three clinics in Louisiana. As one reporter put it, leaving Louisiana with “a single physician” who provides abortion services.30 As Greenhouse and Seigel note, abortion regulations written in the interests of women’s health are legal so long as the regulations are “consistent with ordinary medical practice.”31 But of rhetorical interest here is whether the TRAP laws are actually motivated to promote health-related intentions. In other words, are proponents of these new laws actually interested in protecting and promoting women’s health, or do they see in these laws ways to aggregate discourses in such a way as to block access to abortion services? Greenhouse and Seigel write that the TRAP laws “impose requirements on abortion providers that are not imposed on other medical practices of similar or even greater risk” while achieving the practical consequence of shutting down clinics and eliminating access to abortion services.32 For example, while attempting to establish admitting privileges for physicians who provide abortions, Wisconsin did not have similar requirements for physicians who provide colonoscopies, arthroscopic surgeries, and various gynecological procedures even though the rate of complications for first-trimester abortions is lower than that of

 Greenhouse and Siegel, 1430.  For reporting coverage, see, North, Anna. 2019. The Supreme Court has blocked a Louisiana abortion law—for now. Vox Feb 8. https://www.vox.com/2019/2/7/18215941/louisiana-abortion-­ law-supreme-court-admitting-privileges Accessed 23 Jan. Stein, Michael Isaac. 2019. Abortion access in Louisiana could be reduced to a single physician.” The Lens. Jan 25. https://thelensnola. org/2019/01/25/abortion-access-in-louisiana-could-soon-be-reduced-to-a-single-physician/. Accessed 23 Jan 2020. 31  Greenhouse and Siegel, 1442. 32  Greenhouse and Siegel,1446. For data on how TRAP laws would force clinic closures see 1450–1451. 29 30

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colonoscopies.33 Officials promoting the regulations have been more overt about their consequences for closing clinics than protecting women’s health. An email from an anti-abortion group boasted that such regulations in Texas had “tremendous success in closing abortion clinics and restricting abortion access.”34 What emerges from this analysis is the curation of public health discourses in efforts to restrict and eliminate abortion services. These discursive acts aggregate multiple existing discourses in a strategic attempt to achieve an intention that is apart from the constituent discourses being assembled. While the effort is designed to achieve a long-term effect, the specific activity here is temporary and context-specific. The curation may, at some point, stabilize into a generic activity, but this could only occur once the intention (to restrict abortion services) becomes transparent and sufficiently aligned with the discourse to become naturalized.

Curating the Medical Encounter On a Sunday afternoon in June, my crew was called to a trailer park residence in a neighboring rural outpost where a 28-year-old woman reported being bit by a dog. When we arrived, we found our patient outside on a plywood staircase with her lower right leg wrapped in blood soaked bandages. First responders from the local fire department had arrived before us and applied direct pressure to the wound and wrapped it. She was in  Greenhouse and Seigel include an opinion from the Texas district court which specifically addressed the supposed promotion of women’s health and the intent of the TARP requirements, they quote: “The requirement’s implementing rules specifically deny grandfathering or the granting of waivers to previously licensed abortion providers. This is in contrast to the “frequent” granting of some sort of variance from the standards, which occurs in the licensing of nearly three-quarters of all licensed ambulatory surgical centers in Texas. Such disparate and arbitrary treatment, at a minimum, suggests that it was the intent of the State to reduce the number of providers licensed to perform abortions, thus creating a substantial obstacle for a woman seeking to access an abortion. This is particularly apparent in light of the dearth of credible evidence supporting the proposition that abortions performed in ambulatory surgical centers have better patient health outcomes compared to clinics licensed under the previous regime.” (1455–1456 note 127) 34  Greenhouse, Linda. 2019. A Supreme Court abortion case that tests the court Itself. New York Times October 10. https://www.nytimes.com/2019/10/10/opinion/supreme-court-abortion.html 33

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considerable pain. She told us that at church that morning, her friend had invited her over for lunch. Her friend’s husband thought he had locked up the pit bull in a bed room but the door was not secure and when the dog heard the guest in the kitchen, he nosed open the door, raced out of the room, and bit through her calf on her right leg. After ensuring that the dog was now securely locked in a room, we helped our patient onto our stretcher and moved her to the back of the ambulance. As I unwrapped the blood soaked bandages to inspect the wound, I saw that outside muscle on her right calf had been nearly torn away from the leg. Her right foot was limp and I could see 1–2 inch diameter teeth marks where the dog had pinched and then ripped at the muscle. I dressed the wound, applied a tight wrap to ensure direct pressure, stabilized her leg and then asked my patient what she wanted to help reduce her pain. Through gritted teeth and tears she told me she didn’t want any pain medication and just wanted to be transported to the hospital. It is not unusual to have patients refuse pain medication. Some people do not like the way pain medications, especially narcotics, make them feel; they don’t like the associated loss of control and worry about potential side effects and interactions with other drugs they may be taking. Others may be recovering from addiction, some are just stoic, and plenty probably don’t trust EMS and want to get their care from hospital-based nurses and physicians. In these cases, we try to use “distraction analgesia.”35 Distraction has long been a viable coping mechanism for some types of pain. While the technique can be patient (and situation) dependent, distraction is widely used in pediatrics for nonpharmacologic pain reduction and has been shown in clinical studies, laboratory studies, and even neuroimaging studies to reduce the experience of pain in adults. Kristin Schreiber and colleagues at Brigham and Women’s hospital and Johns Hopkins School of Medicine found that distraction reduced the sensation of pain not only in routine patients but also in patients with a history of making their pain even worse by obsessing about it, what is called  Schreiber, Kristin, Claudia Campbell, Marc Martel, Seth Greenbaum, Ajay Wasan, David Borsook, Robert Jamison, and Robert Edwards. 2014. Distraction analgesia in chronic pain patients: The impact of catastrophizing. Anesthesiology 121:1292–1301. doi: https://doi. org/10.1097/ALN.0000000000000465 35

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“high catastrophizing.”36 In fact, high catastrophizing patients experienced a greater reduction in pain sensation than normal patients. Schreiber’s team used a hand-grip exercise to distract patients from their pain. We don’t have hand grips in an ambulance but we try to use the compressing pressure of a blood pressure cuff, the tension of an IV tourniquet, or the prick of a blood sugar test. But these are temporary and when no longer available, we do our best to curate the situation— assemble relevant and interesting discourses that engage the patient sufficiently to distract them from their pain. Knowing that my patient had come from church, I asked her about the morning’s events, asked her to recount the sermon, asked her favorite hymn. These provided some distraction but not the sort of engagement I wanted, so I asked her about Easter services. Since this was June we were three months past Easter and my patient needed a moment to recall those events. That moment appeared to distract her from her situation and she talked about her dress, a hat she had purchased specifically for Easter services. I asked her about egg hunts, family dinners, anything I could do to keep her on topic and distracted from her physical condition. These are quick, difficult, and nimble conversations. Some patients tell me they know what I’m doing, “you’re trying to distract me!” and I’ll say “absolutely” and ask them another question. But more importantly, for some patients they work. The important component is to find the topics that click and evoke a response. As a curation, distracting analgesia is a temporary, strategic, and semantically ambivalent discursive technique. The discourses I’m aggregating are not for informational purposes even if we engage in routine genres and generic conversations. I don’t particularly care how my patients answer my questions and while it is nice to know what their granddaughter received for Christmas, what color they painted their kitchen, what their grandson does for work in Oregon, or whether or not they put raisins in their Thanksgiving stuffing, what they tell me is entirely incidental to the pain relief (the perlocutionary act) I am attempting to achieve.

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 Schreiber et al., Fig 1.

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Curating Conversation for Patient Assessment Conversation is a site of controversial curations in medical practice. Conversations are the primary form of initial assessment in most medical encounters and patient responses quickly influence every further action throughout the encounter. Conversation also influences treatment throughout the hospital encounter and even future discharge plans. In her essay “Conflict talk in a psychiatric discharge interview” Branca Telles Ribeiro provides an insightful transcript of a conversation between a psychiatrist and a female patient during a discharge interview. Midway through the interview, the physician appears to switch registers from conversational (personal) information to more institutional (diagnostic) information. (11) Doctor /mmmm/ you also have a granddaughter, don’t you?= (12) Patient: =I’ve got a ((little)) sixteen-year old= =granddaughter. (1.4) [raises head and smiles] Doctor: //mmm// Patient: she’s my life [raises head and smiles] (13) Doctor: do you- really?= (14) Patient: =really. I am crazy (about her). I like (her) [ve[smiling] | (15) Doctor: [do you take care of her?= (16) Patient: =I don’t take care of her because my daughter-in-law takes very good care, y’know= [short smile] I just see her, and all that. (I don’t ) (17) Doctor: do you always keep in touch with them? (18) Patient: oh, yes, always . .. [nods]

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well as much as possible I do, y’know doctor. … [nods and smiles, looks at doctor] (19) Doctor: ‘where do you live, Mrs Cardozo? (20) Patient: what?= [lips tighten and frowns]37 At this point the conversation degenerates into short phrases with the patient preferring to nod and provide facial gestures (nods, smiles, frowns, tightens lips). Ribeiro rightly explains this exchange as an example of discursive framing as the physician and the patient move through official, personal, and then back to official frames. At each change in the frame, Ribeiro explains, “a new footing must be negotiated” to keep the conversation intact. Contextually, the interview occurs as the patient is completing an inpatient stay and initiating a move back into the community. Ribeiro notes that here the patient is caught in a middle ground—not still patient but not quite free citizen—and must negotiate both identities simultaneously. The physician, on the other hand, retains an official role and, Ribeiro writes, “the doctor’s reluctance to maneuver the interaction within the patient’s personal framings represents a major tension in the interview.”38 Ribeiro faults the physician for not fully recognizing the discursive movement going on in the interview as the patient transitions from patient to person, which Ribeiro writes is “a necessary process to re-enter the wider world, lest she remains subdued in a passive and dis-identifying role: the role of patient.”39 The physician’s reluctance to engage the patient within a personal frame thus creates tension and strain in the interview and according to Ribeiro, seems discordant with the purposes of psychiatric treatment which would be to help re-integrate the patient with her social and community identity. Ribeiro’s analysis and critique offer useful insights and guidance for medical providers who may not realize how such encounters might prolong or reify passive and dis-identifying behaviors among patients. If one  Ribeiro, Branca. Telles. 1996. Conflict talk in a psychiatric discharge interview: Struggling between personal and official footings. In Texts and Practices: Readings in Critical Discourse Analysis, ed. Carmen Rosa Caldas-Coulthard and Malcolm Coulthard, 185–186. 38  Ribeiro, 189. 39  Ribeiro, 189, emphasis in original. 37

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goal of inpatient care is to enable patients to fully achieve autonomy and self-care upon discharge, ignoring or over-talking a patient’s agency and identity formation certainly impedes and disrupts such goals. At the same time, Ribeiro’s analysis could very well mistake the extent to which the physician’s exchange here is a curation, aggregated from personal conversation and intended to evaluate the patient’s suitability for discharge. While we know little of this patient’s actual diagnosis and treatment, we do know that she has been admitted for “an acute psychotic crisis.”40 Throughout the interview we learn that the patient has a granddaughter who lives with the patient’s son and daughter-in-law. In the discharge interview, the physician has a responsibility to ensure that the patient is not a threat to herself or to other people. In the discharge interview, the physician is curating discourses of personal relationships, questions about family, relationships, and visits to evaluate the potential threat the patient may represent to the granddaughter. Once she learns about the granddaughter, the physician’s questions do not probe visitation (“do you visit her?” “do you see her?” or “does she visit you?”) but dependence and responsibility, “do you take care of her?” The physician’s intention here appears to be focused on understanding the extent to which the grandmother is responsible for the care, security, and nurturing of the granddaughter—a concern what would be entirely within the professional responsibility of the psychiatrist. The curation appears to be revealed when the physician asks “where do you live, Mrs Cardozo?” a question that gets access to the granddaughter as the conversation follows questions regarding frequency of contact, (17) Doctor: do you always keep in touch with them? (18) Patient: oh, yes, always . .. [nods] well as much as possible I do, y’know doctor. … [nods and smiles, looks at doctor] The question about frequency of contact with her granddaughter could be problematic for the patient who wants to appear normal and maintain  Ribeiro, 179.

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the appearance that she has a loving relationship with her son’s family. Yet the hedge, “well as much as possible I do, y’know doctor” and the prior admission that she does not take care of the granddaughter “because my daughter-in-law takes very good care, y’know” suggests that all may not be well within the family unit. Here, the physician can no longer maintain the terministic screen of a personal, friendly conversation about family but must assess and evaluate the extent to which the patient has proximity and access to the child, the extent to which the patient may be a threat to her granddaughter. The patient seems to recognize the deceit here and appears to recognize that the prior conversation was also not actually about the patient’s relationships, her social identity, or her affection for her family. The conversation was a curated assessment about the extent to which the patient may be a threat to her family disguised as a friendly conversation about her family. The physician’s interview, like our attempts to deploy analgesic distraction, curates discourses intimate to the patient and is thereby limited and temporary to the situation and the individual patient context. Some generic subjects (children, grandchildren, care giving) have better stickiness than others. Men seem to engage better with topics about sports and work, subjects that may not have suited the above interview. But, these are not semantic discourses in the way the patients may interpret them but are evaluative (or distracting) to achieve an intention quite separate from the generic discourses the curation was formed.

Curating Intent through Textual Silences The prior examples of curations showed how discourses can be aggregated to create a separate strategic discourse. This final example shows discourses curated by strategically leaving out text. Thomas Huckin has shown how textual silences can contribute to discursive acts in a continuum from useful and sympathetic activities to manipulative and

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ideological pursuits.41 Whereas Huckin’s analysis examines five salient types of textual silences (speech-act, presuppositional, discreet, genre-­ based, and manipulative), I would like to focus on his expanded examination of manipulative silences as a unique type of discursive curation. Huckin defines manipulative silences are “those that intentionally conceal relevant information from the reader or listener, to the advantage of the writer or speaker.”42 Manipulative silences are differentiated from other types of textual silences, Huckin writes, in that they depend for their success on readers or listeners not recognizing their omission. Manipulative silences are common in advertising, political campaigns, press releases, and a perhaps most of social media. Huckin gives the example of an advertisement for a Jeep Cherokee that extols its value as an off road vehicle but not reveal the vehicle’s fuel economy. Huckin explains that while textual silences in any form do not have an overt linguistic form, presuppositional, speech-act, and genre-based silences are “tightly constrained by linguistic, conversational, and generic norms.”43 Manipulative silences, on the other hand, are much more difficult to identify as they rely on recognizing sociopolitical, cultural, technical, or rhetorical factors that are left out of the proposition. In defining manipulative silences as omissions that “intentionally mislead or deceive the reader or listener in a way that is advantageous to the writer/speaker” Huckin is noting the curative component of these discourses. As with other curations, agents intentionally aggregate discourses to achieve a strategic intent but here, the intent is achieved by also intentionally  Huckin, 347–372 (see note 131). Readers are encouraged to examine Huckin’s essay for a more detailed elaboration of each form of textual silence. Huckin elaborates speech-act silences as cooperative silences that further communication. The speech-act silence is intended to have communicative import and the audience can interpret this import through shared understanding. Presuppositional silences are found when writers or speakers omit knowledge they assume is already known or familiar to their audiences. Presuppositional silences are defined not by deceit (the information was omitted to deceive or distract the audience) but by a tacit contextual understanding between author and audience. Discreet silences are conducted when the writer or speaker avoids sensitive topics to avoid offending, insulting, or violating social or legal codes. Cases of confidentiality, politeness, and tactfulness could all be reasons for a discreet silence. Genre-based silences are conventional omissions naturalized in discursive form. For example Huckin notes that obituaries rarely mention negative or embarrassing attributes of the deceased and American resumes leave out demographic information like age, race, religion, or ethnicity. 42  Huckin, 351. 43  Huckin, 353. 41

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o­ mitting salient discourses. The manipulation here is intentional notes Huckin and can be identified by identifying the full set of discursive options available to the agent and then identifying which options were excluded. “If there is no reason to think that the writer is incompetent,” Huckin notes, “these omissions can be construed as, in some sense, intentional.”44

Intention, Textual Studies, and Instrumental Discourses To conclude this project, I would like to return to an essay that helped spark my motivation to study intention in professional discourses. In his essay “Three kinds of intention” Michael Hancher differentiated intention into three types “(1) the author’s intention to make something or other (programmatic intention); (2) the author’s intention to be (understood as) acting in some way or another (active intention); (3) the author’s intention to cause something or other to happen (final intention).”45 Hancher argues that, at the time, most of the debate regarding intention in criticism confused programmatic intention with active intention, in other words, confused what the author intended to accomplish with what the author wanted the actual accomplishment to represent. It confused empirical truth for meaning. My intention to write a book about intention (programmatic, empirical) should not be confused with my intent that this book would have audiences reconsider the role of intention in instrumental discourses (active, meaning). Hancher puts it this way, “the difference between programmatic intention and active intention is the difference between an intention to do something oneself … and an intention that the thing one has made mean … something or other.”46 Active intention cannot be separated from the text itself and therefore, according to Hancher, is ultimately mitigated by the reader. While the author  Huckin, 355.  Hancher, Michael. 1972. Three kinds of intention. Comparative Literature 87: 827–851,829. 46  Hancher, 831. 44 45

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may make subsequent comments and helpful or distracting gestures about the book, ultimately the ability of the book to accomplish its intended goal is out of the author’s hands once the book is complete.47 A final intention, according to Hancher, is “an intention to cause an effect of one sort of another; it defines whatever the author wishes to accomplish by means of [the] completed work.”48 Hancher argues that active intentions are relevant and have bearing on the meaning and evaluation of a literary text whereas programmatic and final intentions are unrelated to the quality of the text. Programmatic complaints are not critiques of the work but of the author (did the author complete the necessary task?). Complaints regarding the final intention of the work relate to the empirical function of the work (what did it cause to happen?) and not its aesthetic significance. Citing Austin, Hancher writes, “the illocutionary force exerted by this work is independent of its perlocutionary consequences.”49 Here we find both the birth of instrumental discourse as a focus of disciplinary study and the importance that intention holds within such work. Professionals, to take one example of instrumental discourse, are tasked with accomplishing things with texts. As such, professional discourses should be held to programmatic intention (did the professional complete the task?) and final intentions (what was the result of the discursive activity?). Investigating intention in professional discourses examines whether and how the professional could translate the intentional discourse (illocution) into a result (perlocution). Here we are interested in the results and the effects of intentional discourses, their meaning, not their value or significance as aesthetic texts or productions (unless textual aesthetics factor into its perlocutionary enactment). Thus value in professional discourse assesses what the discourse accomplished.

 Hancher, 830–832  Hancher, 834. 49  Hancher, 850. Recall, illocutionary refers to an intentional utterance, perlocutionary refers to the utterance’s effect. Turning to my partner in the ambulance, I say “lights.” The intent (illocution) of my statement is “turn on the lights and sirens.” The perlocutionary effect is we drive code 3 (lights and sirens) to the call. What Hancher explains here is that my statement “lights” does not necessitate that my partner will turn on the lights and sirens. I may intend that we drive lights and sirens but my partner may disagree. 47 48

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Professionals are expected to advocate for specific and particular knowledge-based and conceptual values within social, economic, and cultural exchanges: justice, health, knowledge, or learning, for example. The professional provides advice and direction in pursuit of these goals. In this way, the professional’s intentions, as a professional, are largely prescribed: to advocate for those values inherent to that profession. A physician’s intention is to advocate for the health. The lawyer’s intention is to advocate for justice. The academic must advocate for the pursuit of knowledge. To do otherwise would be unprofessional. Since these intentions are known and are commensurate with the status, orientation, and responsibility of the professional, the programmatic and final intentions of the professional should be known and available for evaluation. The ways in which the professional achieves these values, the professional’s style, significance, and aesthetic presentation, what Hancher considers “active intention,” are then subordinated to the other forms of intention. This then brings us again to the ethical questions associated with discursive curations. Does the intended effect of the curation make up for its deceptive and manipulative discursive aggregation? Can we claim that if the curation is deployed for good—pain relief or protecting a minor— the curation is ethical but if deployed to close essentail medical services or hide technical problems and engineering mediocrity the curation is corrupt? Of course, such a position becomes highly dependent on one’s own politics, values, and consumer behaviors. Here, the layers of intention discussed above become helpful. Perhaps the ethical test for curations then is transparency. If the curation is structured in a way that reveals its aggregated discourses we can claim that the curation was deployed appropriately. In my own clinical practice, I have begun telling my patients what I am doing and even though they know I am attempting to distract them from their pain, in most attempts we are able to still mitigate their sensation of pain. I have had patients ask me to distract them and still have been able to successfully break their mind from their pain and I have had patients voluntarily and knowingly distract themselves (tapping themselves on the forehead for example) during medication or vaccine injections and successfully distract needle anxiety and injection site pain.

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As we saw in Chap. 2, intention is not something to be discovered, hidden, naturalized, or obscured within professional discourse. Instead, in the field of professional discourse, intention is the transparent deployment of action. Here intention is differentiating and defining: Intention becomes an ethical, productive, and defining requirement for professional communication.

8 Utility/Postscript

Looking back over the decade during which this book took place, my “intentional humanities” remains a work-in-progress. Certainly, I am a different person than the confused linguist who walked out of the neurologist’s office. Apart from a few blood tests my primary care physician ordered (lyme, gout, vitamin B12, vitamin D), I gave up on trouble shooting the symptoms and opted for a less-is-more approach. With good days and bad, I got back into triathlon and have had the pleasure of travelling and completing events across the country. I have been practicing as a paramedic for six years and while I still miss my share of IVs, I have started training new medics as part of a University of Vermont/ Northern New  York paramedic school extension program out of Elizabethtown Hospital in the Adirondack Mountains. We hope to expand ALS care throughout Northern New  York and thereby enable these communities to have well-prepared and diligent pre-hospital care despite their isolation and rural locations. I have also taken my own advice (from Chap. 5) and have started some part-time work as a community paramedic in addition to my normal 911 pre-hospital role. Community paramedics are EMS’s anti-heroes. Rather than ride the rush of 911 calls, community paramedics quietly and

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discreetly treat appropriate patients in their home. Also called “Mobile Integrated Health Care” and “ED at Home,” the intent of this hybrid of primary, palliative, and emergency medicine is to avoid costly and potentially risky emergency department visits and hospital admissions—when possible and appropriate— and allow people to stay and heal in their homes.1 After a career in communications and public relations, most recently as a Director and a Vice President for Corporate Communications at Canton-Potsdam Hospital, Rebecca gave up the C suite for a career in nursing. After returning to school for her RN, she is now working as an emergency department psychiatric nurse and is close to a planned Doctorate in Nursing Practice. She worked regular shifts throughout the COVID-19 pandemic and miraculously (at the time of writing) has not contracted the disease. In March 2020, I contracted COVID-19, most likely while caring for a patient in acute respiratory distress. My physical recovery took approximately two months after which I returned to a clinical world transformed by masks, goggles, surgical gowns, hats, and palpable fear. While I feel more or less recovered, the disease has left psychological and emotional scars. I admit to tearing up when I finally received my vaccine. My relief was partially for myself but mostly for my pre-hospital colleagues who had been taxed beyond reasonable expectations and for hospital staff and clinicians, people for whom extraordinary suffering was matched by their truly heroic bravery. An end appeared to be in sight. At the time, it was implausible to think that two years later we would still be in a crisis. The coronavirus pandemic exposed and made horribly worse existing problems in America’s failing healthcare systems: In a few  The United States Center for Disease Control and Prevention reports that each year approximately 1.7 million hospitalized patients contract a health care-associated infection (HCAI) and one in 17 die from the exposure. Haque, Mainul, Massimo Sartelli, Judy McKimm, and Muhamad Abu Baker. 2018. Health care-associated infections—an overview. Infectious Drug Resistance. 2018: 2321–2333, doi: https://doi.org/10.2147/IDR.S177247. On Community Paramedicine and Mobile Integrated Health Care, see: “Community Paramedicine and Mobile Health” Journal of Emergency Medical Services website resource: https://www.jems.com/community-paramedicine-­ and-mobile-health/. See also: Guo, Bing, Paula Corabian, Charles Yan, and Lisa Tjosvold. 2017. Community Paramedicine: Program Characteristics and Evaluation. Institute of Health Economics Report. Edmonton, AB: Institute of Health Economics; and notes 336 and 446 above. 1

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short months American health care witnessed millions of patients losing insurance coverage through coronavirus-related layoffs and unemployment, vast racial and ethnic disparities in who contracted and died from the disease, a collapse of public health systems across the country, millions of people infected, and to date, nearly 800,000 friends, family members, colleagues, and heroes dead. In 2020, COVID-19 was the third leading cause of death for Americans between 45 and 85 years old and the second leading cause of death for Americans aged 85 and older.2 The pandemic also revealed a broken scientific communication infrastructure as simple and effective actions like mask-wearing, social distancing, and voluntarily isolating oneself after a possible exposure became politicized and curated as a proxy for religious adherence, peer group loyalty, ideology, and patriotism. That prior generations of Americans had successfully undertaken such actions was immaterial and largely forgotten.3 The stress of the pandemic, borne disproportionately by frontline healthcare workers, EMTs, paramedics, nurses, respiratory therapists, and physicians, became evident in clinician suicide, early retirement, and other psychological and behavioral traumas.4 The social, psychological, systemic, and human problems COVID-19 revealed are difficult, lasting, and complex issues that will not be remedied with a vaccine. These are complex, deep, and multilayered problems  Blumenthal, David, Elizabeth Fowler, Melinda Abrams, and Sara Collins. 2020. Covid-19— implications for the health care system. New England Journal of Medicine 383: 1483–1488. On causes of death in 2020, see Woolf, Steven, Derek Chapman, and Jong Hyung Lee. 2020. Covid-19 as the leading cause of death in the United States. JAMA 325: 123–124, doi: https://doi. org/10.1001/jama.2020.24865. 3  A Bell Telephone advertisement from 1910 shows a husband and wife alone in their house with the caption “When In Quarantine People who are in quarantine are not isolated if they have a Bell Telephone. The Bell Service brings cheer and encouragement to the sick, and is of value in countless other ways. Friends, whether close at hand or far away, can be easily reached because Bell Service is a university service.” While the advertisement pre-dates the 1918 influenza epidemic, it suggests that Americans at the time were used to taking precautions from smallpox, cholera, bubonic plague, or other infectious diseases. See: https://www.snopes.com/ fact-check/1918-quarantine-ad-for-phone/ 4  Arespacochaga, Elisa. 2020. Shining a Light on Physician Suicide, American Hospital Association, September 17. https://www.aha.org/news/blog/2020-09-17-shining-light-physician-suicide. See also, Kingston, Amanda. Break the Silence: Physician Suicide in the Time of Covid-19. Missouri Medicine 117: 426–429. Knoll, Corina, Ali Watkins, and Michael Rothfeld, 2020. ‘I Couldn’t Do Anything:’ The Virus and an E.R. Doctor’s Suicide. New York Times, July 11. https://www.nytimes. com/2020/07/11/nyregion/lorna-breen-suicide-coronavirus.html 2

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that require substantial changes in the ways we interact, communicate, empathize, collaborate with, and trust each other. They will require new considerations for how we hold each other accountable for intentions revealed, disputed, and obscured. An intentional humanities will also require a different, more complex, and better-integrated approach to expertise, training, and pedagogy. If we hope to influence spaces and problems co-occupied by scientists, engineers, and clinicians, humanists must develop technical competence and subject area knowledge that does not seek to replace their STEM colleagues but is sufficiently informed to be useful. As Herndl noted, there is a very real concern here about “going native” and losing perspective of the unique and critical contributions a humanist provides. At the same time, cultivating and curating such a role takes time, practice, and patience. For me, it started with a basic EMT course, an undergraduate course in microbiology, and then five years later, a paramedic certificate. It continues with subscriptions to the medical literature, podcasts, emergency medicine conferences, and continuing education. There are times when I wonder if I am still sufficiently a humanist and more frequently I worry about imposter syndrome when I am teaching pathophysiology in my medical writing courses. I fully recognize that there are experts who can do a much better job in each of the individual components of what I am doing—a cardiologist, epidemiologist, historian, ethicist, creative writer, emergency medicine physician, full time paramedic—but few are able (or desirous) to work in the difficult and complex gaps between and among such specialty areas. Yet it is in these very gaps where our most stubborn and enduring problems will be best mitigated by people who are willing to collaborate and contemplate life beyond their disciplinary intents. In 2021, I joined the Biomedical Engineering department at my university. Situating humanities scholars (more frequently writing or technical communication faculty) in STEM departments is still rare but not unusual. As Julie Ford has explained, when discussing her own move to the Mechanical Engineering department at New Mexico Tech, the role enables much greater levels of collaboration in roles and on projects typically not available to outsiders. Working with graduate students, undergraduates, and faculty within the department, Ford notes that proximity

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and daily interaction are crucial for productive collaboration and interdisciplinary trust. Proximity makes collaboration accessible and routine.5 “Going rogue,” as Ford puts it, also means working on different problems and in many cases in yet to be defined roles. The difficulties then are both intellectual and social/communal. Ford notes the challenges associated with learning a new scholarship, of having to let go of some more familiar trends in her prior research, and prioritizing her research and teaching on problems at hand. My move to Biomedical Engineering has echoed Ford’s experience. My new department has been gracious and welcoming and I have been fortunate to have colleagues who recognize the limitations of technological determinism. Our students are increasingly interested in better understanding the human dynamics associated with technology and problem solving. Coming out of our joint COVID-19 experience, they saw how human behavior blunted and upended engineering solutions. We recognize immense challenges here, challenges I’ll term utility and integration.

Utility I hope that my patients, fellow clinicians, and interns see me as a deliberate and intentional care provider who is attentive equally to medical and human concerns. But my time in practice is still young and such outcomes still seem premature and theoretical. Some local and practical solutions are emerging. Effective in February 2018, the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS) approved reimbursement for specialized “Z-codes,” billing codes that can be assigned to social determinants of health. The 2018 change stated that any clinician involved in the care of the patient could assign the code. This provides a system-wide incentive for clinicians (nurses, doctors, social workers, community health  Ford, Julie Dyke. 2018. Going rogue: How I became a communication specialist in an engineering department. Technical Communication Quarterly 27: 336–342. See also: Maylath, Bruce, Jeff Grabil, and Laura Gurak. 2010. Intellectual fit and programmatic power: Organizational profiles of four professional/technical/scientific communication programs. Technical Communication Quarterly 19: 262–280. 5

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workers, paramedics) to report and act on social needs that influence health, access to care, and general well being.6 For example, codes can diagnose “problems related to education and literacy,” “problems related to employment and unemployment,” and “other problems related to primary support group, including family circumstances” which can include an absent family member, chronic loneliness, stressful life events, or family disruptions. These seem to be issues that an intentional humanities could help to identify and address, especially as they involve education, literacy, understanding and translating risk, communication, adjustment, empathy, insight, and interpersonal support. A second, crucial, and immediate utility would seem to be repairing trust between science and certain sectors of the public. In a New England Journal of Medicine review of vaccine skepticism, Lisa Rosenbaum writes, “Though COVID hasn’t changed human nature, its devastating consequences have highlighted the gap between what is true and what people believe.”7 Rosenbaum recalls critically ill patients who continued to deny the existence of COVID-19. In my own pre-hospital experiences, I cared for multiple patients who told me that they tragically “didn’t believe” in COVID until they contracted the disease. I agree with Rosenbaum when she writes that most of these people “are simply bewildered and no longer know whom or what to trust.”8 My patients felt afraid and betrayed. They unfortunately had trusted their most intimate family and friends and those relationships had betrayed them. For many of them, their tragedy was equally spiritual and physical. Citing vaccine-confidence expert Heidi Larson, Rosenbaum astutely concludes, “I think Larson is alluding to a more fundamental tension in the relationship between science and society that the pandemic has magnified: science may tell us what’s true, but it can’t tell us what’s

 For additional information see: American Hospital Association, ICD-10-CM Code Categories, https://www.aha.org/system/files/2018-04/value-initiative-icd-10-code-social-determinants-of-­ health.pdf; for detailed descriptions, see: https://www.icd10data.com/ICD10CM/Codes/Z00-Z99 7  Rosenbaum, Lisa. 2021. No Cure without Care—Soothing Science Skepticism. New England Journal of Medicine 384, 1462–1465, 1462. 8  Rosenbaum, 1462–1463. 6

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meaningful.”9 Rosenbaum’s insights echo the themes presented ­throughout an intentional humanities. She writes that while professionals (physicians for Rosenbaum) were once solely the creators of knowledge, “we now must learn to be its curators as well.”10 The project of medical curation, helping patients synthesize truth and belief, assisting with translating medical instructions and diagnostic information, and teaching health literacy, aligns with Herndl’s advocacy for an engaged RSTEM and other similar projects developed by scholars studying the rhetoric of health and medicine, medical humanities, and professional communication. These will become vital projects over the next decade for those post-disciplinary scholars who will take it upon themselves to develop technical knowledge and competency in multiple disciplines in addition to their primary training in textual studies.

Integration Concluding her review, Rosenbaum writes, But to the extent that vaccine hesitancy reflects a loss of faith in our health care system, this moment should force us to examine the ways in which our system is no longer deserving of that faith. The path forward, then, isn’t to compromise science by turning it into an art; rather, it’s to stop trying to turn the art of medicine into a science.11

Since the first draft of this manuscript was completed, there have been several high-profile calls for greater integration between the humanities and the applied sciences. For example, a July 2020 editorial in the Annals of Internal Medicine reported recommendations from Restoring the Story Task Force of the American College of Physicians. The authors wrote, “We believe it is imperative that clinicians reclaim the clinical note as a means of showing the cognitive processing involved in turning medical 9  Rosenbaum, 1463. For Larson citation, see: Larson, Heidi. 2020. Stuck: How Vaccine Rumors Start – And Why They Won’t Go Away. New York: Oxford University Press. 10  Rosenbaum, 1464. 11  Rosenbaum, 1465.

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information into a thoughtful assessment and plan.” “Doing so,” the authors continued, “could also more effectively tell patients’ stories in the context of their life circumstances and community.”12 In December 2020, the Association of American Medical Colleges published The Fundamental Role of the Arts and Humanities in Medical Education.13 Acknowledging a crumbing and discordant American healthcare infrastructure, the authors, write, “The first two decades of 21st century medicine have witnessed significant transformation in health care delivery, marked health disparities, civil unrest, unprecedented rates of physician burnout and suicide, and unforeseen public health crisis in the forms of the opioid epidemic and the coronavirus pandemic.” To this list we can add increasing levels of distrust in formal science and medical institutions, increasing rates of chronic diseases, patients who do not understand their diagnoses, do not adhere to medication or therapy, or who overuse inappropriate medical resources (emergency departments) for unnecessary and avoidable care. As we saw in Chap. 4, our colleagues in STEM disciplines are again calling for greater collaboration and integration with the humanities and arts. The authors of the AAMC report claim that greater exposure to the humanities and arts can address and improve resiliency and engender a clinical perspective that is more beneficial to both patients and physicians than what has been learned in siloed, isolated, and narrow areas of specialization. The authors of the AAMC report write, “Now more than ever, physicians must learn to interweave their developing scientific knowledge with emotional intelligence, critical thinking skills, and an understanding of social context.”14 The goals of this integration, they write, include, “tolerance of ambiguity and paradox, sensitivity to form in language, and comprehension of patient stories.” The benefits they argue include “ingraining aspects of professionalism, empathy, and altruism, enhancing clinical communication and observation skills, increasing

 Gantzer, et al. 380. (see note 376).  Howley, Lisa, Elizabeth Gaufberg, and Brandy King. 2020. The Fundamental Role of the Arts and Humanities in Medical Education. Washington DC: Association of American Medical Colleges. 14  Howley et al., 1. 12 13

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interprofessionalism and collaboration, [and] decreasing burnout and compassion fatigue.”15 These are crucial and overdue investments. While the report provides useful examples for integrating subjects like literature, narrative medicine, music, art, history, dance, and creative writing into medical education, the authors do not prescribe how such integration should occur, what subjects should be taught, or what these experiences should look like. They leave such specifications to the humanists and artists. This is, of course, how it should be. At the same time, responsible work on our part will need to embark on such projects with renewed attention, careful and astute concern for what we are doing, and a transparent discourse about our intentions. How we go about these projects, the solutions we provide, and the actual beneficiaries of our actions will mark and reveal our intentions and our willingness to work in actual partnership with other disciplines. The examples provided in the report are almost exclusively programs and experience within medical schools themselves: a visual arts course at Harvard, a Theater and Drama program at Northwestern, a course in Jazz improvisation at Penn State. This leaves open the question about undergraduate preparation for not only medicine but other professions. What might an actually integrative, intentional humanities approach look like at the undergraduate (or graduate) curriculum? How might such an approach move beyond disciplinary siloes and instead create meaningful, robust, and lasting experiences and knowledge that are relevant for both science and the humanities? What can the humanities and arts do to achieve the sorts of goals and expectations placed on us when organizations like the AAMC or our own engineering departments ask for our expertise? How do we translate our expertise, knowledge, and practices to students, faculty, and professionals in other disciplines whose own educational training left them without a language or perspective for considering human dynamics, artistic endeavors, or the societal dynamics that complicate and frustrate their technical solutions? These, of course, are questions for further and future projects. One of the intentions one has when starting a book project is, of course, to 15

 Howley, 5.

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complete it (programmatic intention). What I have hoped to offer in this book (my active intention) has been a different way forward for humanities-­based textual studies. This intention emerged from my own efforts to forge tools and instruments for better engagements and experiments in the intersections of humanity and science. Central to my efforts, and to many of the examples and programs I read in the AAMC report and elsewhere, have been the formation, recognition, and performance of intentions as practical equipment (final intentions). Throughout this book I have attempted to offer examples of complex and sticky problems that could be better addressed by collaborations between textual scholars working with an intentional humanities orientation and colleagues in technical disciplines: projects like finding ways to work with patients to improve medication, diet, or exercise adherence; working in preventative care to reduce behavior-related morbidity and mortality; working with clinicians and patients to find better ways to heal addiction; working with psychiatrists and social workers on ways fundamental humanities talents like music, art, writing, and design can aid in mental health, resilience, anxiety, and depression; and working alongside public health experts on ways to control the spread of infections, reduce youth incarceration rates, and improve access to healthcare in underserved, at-risk, and disadvantaged communities. Other opportunities exist in fields like process improvement, metrics, and quality that require robust critical thinking, an understanding of human dynamics, a creative approach to assessment and designing metrics, and a sensitive, understanding, and humane approach to program implementation. Such work need not be entirely programmatic. For example, we can forge hybrid projects that examine the role of intention within medical treatment. To what extent does healing, chronic disease management, and self-care require that patients develop, (re)gain, and (re)deploy intention? What is the role of intention in self-care and how can clinicians effectively work with patients in ways that advocate for and appreciate a patient’s intentions? How might intention inform one’s own emotions and reactions to providing or receiving a diagnosis? We can ask how intention influences decision making. How does intention influence why, how, and when people make mistakes, when are

8 Utility/Postscript 

233

people willing to admit to an error, and how can mistakes be corrected? How does intention enable us to realize, adapt to, enable, or resist change? How does intention influence interpretation and cognition, how and what we see, how we process our environment, and how we distinguish what is meaningful from what is merely significant. These represent productive directions and ongoing crucial problems that can bring together fields and practices that for far too long have been held apart to the detriment of our communities and ourselves. – Worcester, MA May 2022.

Index1

A

Accountability, 63, 66, 74, 77, 86, 99, 109, 122, 147n35, 183, 207 Action, vii, 9n8, 11, 15, 20n35, 22, 30, 31, 36, 40, 55, 58n108, 64, 66, 73, 74, 83–86, 85n45, 85n47, 87n53, 93, 94, 97, 104, 107, 109, 119, 134–136, 143, 143n25, 144n26, 171, 178, 184, 184n18, 190, 214 as announcing intention, 86 examining intention through, 171 as morality and motion, 136 in prehospital care, 143 political, 56 Adherence, 43, 153, 159, 206, 208, 225 medications, 129 to medications, 160

Affinity and persuasion, 203 as persuasion, 90, 91, 93 Agency vs. intention, 51 Aggregation, 44, 59n109, 64, 93, 94, 130, 136, 181, 202, 205, 207, 221 Aitken, Kenneth J, 108 Algorithm, 35, 36n32, 154n47, 176, 176n2, 181, 182, 185, 188, 189 ALS advanced prehospital care, 138–143, 139n14, 140n16, 140n17, 141n18, 223 Ambiguity, 30, 31, 79, 230 Ambulatory care-sensitive conditions, 151

 Note: Page numbers followed by ‘n’ refer to notes.

1

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 B. Faber, The End of Genre, Postdisciplinary Studies in Discourse, https://doi.org/10.1007/978-3-031-08747-9

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236 Index

American life expectancy, 145 American Recovery and Reinvestment Act, 17, 146 Analytics, 18–21, 19n34, 138, 167, 173–175, 177, 178, 178n7, 180, 181, 188–192, 195 as micropractices, 189 and transparency, 174 Anscombe, G.E.M., 26, 30, 31, 52, 59, 85, 85n46, 86, 97, 115, 116, 184, 184n18, 203 Aristotle, 176, 177n4, 181, 189 Artificial intelligence, 35 and deprofessionalization, 182n13 Austin, John, 36, 37, 39, 40, 42–44, 220 Autonomy, 78, 80, 81, 162, 162n69, 198, 198n1, 198n2, 201, 216 enhanced, 201 B

Bartesaghi, Mariaelena, 53, 54 Beane, Billy, 19, 177 Beardsley, Monroe C, 64, 64n124, 64n125, 64n126, 75–77, 75n12, 75n13, 75n14, 75n15, 75n16, 75n17, 76n18, 77n21, 77n22, 77n23, 80, 84, 93–97, 97n83 Benn Michaels, Walter, 71, 71n4 Big data, 18, 20, 173–175, 174n1, 178n7, 181, 183n14, 189, 190 Biglan, Anthony, 105, 105n14, 106, 109 Bitzer, Lloyd, 88–91, 88n57, 88n58, 89n59, 89n60, 89n61, 89n62, 89n63, 90n67, 94, 134, 204

Blumenberg, Hans, 128 Bourdieu, Pierre, 38, 38n44 Braman, Donald, 90, 90n65, 92, 92n73 Brody, Howard, 201, 201n8, 201n9, 201n10, 201n11, 201n12, 201n13, 202n14 Brown, Gillian, 32–34, 32n19, 32n20, 32n21, 32n22, 33n25, 38n43, 91, 92, 92n71, 92n72, 92n73, 163n70 Brown, Gillian and George Yule, 32 Burke, Kenneth, 17, 29, 31, 52, 134, 135, 136n9, 171, 204 C

Canguilhem, Georges, 105 Caprette, David, viii, 7, 7n4, 8 Centers for Medicare and Medicaid Services, 17, 146, 151, 227 Chouliaraki, Lilie, 47, 111n32, 207, 207n21, 207n22, 207n23, 207n24, 208, 208n25 Cobb, Sarah, 50–52 Cognition, 16, 28n7, 33–35, 37, 83n43, 85n45, 105, 107, 108, 110, 169, 170, 229 cultural, 90 Community paramedicine, 150n37, 205n15 Complementarity between textual intent and intent that motivated textual production, 46 Context, 41–43 COVID-19, 43, 67, 224, 225, 227 Critical discourse analysis

 Index 

criticisms of, 53 and inability to explain how texts enact meaning, 50 Curation, ix, 22, 55, 56, 173, 204, 205, 207, 209, 211, 216–218, 221, 229 and distraction form pain, 213 in patient interviews, 214 in psychiatric evaluation, 216 as textual silences, 217 D

Data capture in video games, 175 Davenport, Thomas, 19, 19n32, 178, 178n8 Dear, Michael, 119–121, 120n53, 120n55, 121n56, 121n57 Derrida, Jacques, 38n41, 39n47, 40–46, 44n58, 44n59, 52, 55, 66, 67, 67n134, 77n20 Dewey, John, 11, 12, 56, 57, 57n102, 58n108, 118n48 Diagnosis as intent, 35 Directed intention, 17, 66, 134, 135, 204 Discharge by 11:00, 184, 185, 190 Discourse accomplishment, 220 action, 36 aggregation, 204, 205, 208–210, 213, 218 alchemic, 112 competing, 89 constructivist agnosticism toward intention, 110 contradictions, 29

237

crossing, 157 curation in medical interview, 216 disingenuous, 65 engineering, 114 fictional, 89 heterogeneity, 207 humanist, 100 hybrid, 207 institutional, 183 instrumental, 220 intention and subjective, 30 naturalization, 74, 211 omission, 219 oppositional, 103 origin and heterogeneity, 41 performative, 37 persuasive, 26 political, 63 post-truth, 66 production, 40 professional, vii, ix, 58, 66, 72, 207, 209, 219, 220 public, 56, 67, 74, 89, 99 public health, 211 retroactive justification, 124 rhetorical, 29, 88 stability, 208 transformations, 209 Discourse analysis and movement to action, 53 Discourse of intention, 5, 28 Discourse studies, 29, 29n8, 32, 33 Discursive features lack of innate meaning, 45 Disease stigma, 195 Disingenuous framing, 66 Distraction analgesia, 212 Dramatistic, 30, 31, 133, 177

238 Index

Drexler, Eric, 101n2, 102 Dreyfus, Herbert, 189–191, 189n27, 189n28, 190n30, 190n31, 191n32, 191n33, 196, 196n40 Durable, 28, 39, 41 Duranti, Alessandro, 29n8 Dutton, Dennis, 73n9, 84, 84n44, 85n45, 86–88, 86n50, 86n51, 87n52

Exigence, 87–89, 91, 93, 94, 99, 155, 204 contrived, 89 Expedience, 70n2, 80, 176, 181, 188, 191 Experiment, 31, 57, 59, 130, 134, 195 F

E

EHR, see Electronic health records Eigler, Don, 102 Electronic health records (her), 146, 165, 168, 169n85, 170 and loss of context, 170 Electronic medical records (EMR), 17, 146, 164, 165, 167, 168n81, 169, 171 and patient communication, 167 research, 141 Embry, Dennis, 105, 105n14, 106, 109 Empirical, 15, 19, 26, 30, 66, 70, 72, 74, 76, 77n23, 79, 80, 82, 84, 87, 89, 91, 93, 93n75, 93n76, 94, 100, 140, 143, 219, 220 Empiricism, 74 EMR, see Electronic medical records English departments, 29, 73, 76n18 Ethics, 12, 22, 43, 60, 66, 76, 86, 88, 99, 109, 113, 126, 129, 136, 174, 174n1, 178, 180, 202, 221 and curations, 205 Event, 37, 43, 44, 56, 100, 113, 140n17, 147, 159n64, 164, 186, 191

Faber, Rebecca, 14, 224 Factish, 190 Failure of speech acts, 43 Fairclough, Norman, 47, 111n32, 166n79, 207, 207n21, 207n22, 207n23, 207n24, 208, 208n25 Faith, 229 Fee-for-service, 151, 152n39, 154 Feynman, Richard, 101 Ford, Julie Dyke, 226, 227 Form/action, ix, 6, 29, 32, 37, 58n108, 60, 74, 76, 81, 82, 84, 86, 88, 89, 93, 94, 102, 124, 128, 130, 135, 157, 159n64, 162, 164, 176, 181, 189, 191, 200, 205, 214, 218, 218n41, 230 early for urban design and nanotech, 120 Foucault, Michel, 16, 16n26, 16n27, 17n28, 128, 128n75, 128n76, 128n77, 130, 130n82, 131, 131n83, 131n84, 157, 157n55, 157n56, 157n57, 159, 189, 189n27, 190 Fowler, Roger, 53 Free primary care clinics, 150

 Index  G

Gawande, Atul, 142, 142n24, 143, 160–162, 160n66, 161n67, 161n68 Genre, 2, 22, 39, 56, 66, 72–74, 83n43, 86–88, 87n53, 92–94, 93n76, 94n77, 99, 160, 188, 198, 200, 202–208, 206n16, 208n25, 213, 218 disappearing in music, 206 as encoding ideology, 208 and intention, 50 as naturalizing intent, 55 as obscuring rules, 44 and suppressing intention, 51, 55 Greenhouse, Linda, 209, 209n28, 210, 210n29, 210n31, 210n32, 211n33, 211n34 Grey goo nanotechnology criticisms, 103 Grice, Paul, 21, 33, 33n25, 34 H

Halliday, M.A.K., 46, 49, 51, 52 and design, 49 Hancher, Michael, 219–221, 219n45, 219n46, 220n47, 220n48, 220n49 Hapgood, Fred, 101 Harris, Jeanne, 19, 19n32, 178, 178n8 Harvey-Brown, Richard, 163 Hayes, Steven, 105, 105n14, 106, 109 Healthcare systemic problems with US, 144 Health Insurance Portability and Accountability Act, 18

239

Hermeneutics, 71n4, 79, 189n27, 190 Herndl, Carl, 11n13, 62, 62n117, 62n118, 63, 63n119, 63n121, 226, 229 Heroes in medicine, 17, 142–145, 149, 160–162, 223, 225 Heterogeneity, 29, 41 of intentions, 44 Heuristics, 5, 17, 20, 134, 166, 173, 175–181, 183n14, 184, 186–188, 192, 195 algorithmic, 181 electronic, 181 Hirsch, Eric D., 71, 71n3, 77–82, 77n24, 78n25, 78n28, 78n29, 78n30, 79n31, 79n32, 79n34, 79n35, 79n36, 80n37, 93, 94n77 Huckin, Thomas, 21, 21n36, 22, 22n37, 86, 86n49, 87n53, 217–219, 218n41, 218n42, 218n43, 219n44 Human genome, 58n108 Humanitarian ideals in science, 127 Humanities, vii, viii, 11, 11n13, 11n14, 29, 58, 60–62, 61n113, 66, 69, 72, 81, 81n40, 98, 100, 110–112, 116, 119, 126n70, 129, 191, 191n34, 195, 223, 229, 230 intention within, 5 Humanities-based critiques of medicine, 160 Hybridity, 22, 87, 207–209

240 Index I

Ideological tyranny, 43 Illness patient experience, 158 Individualistic orientation in CDA, 50 Inheriting truth as ethically perplexing, 43 Instantiation, 58 Instrumental discourse, 220 Integration, 18, 107, 111, 111n33, 195, 229–231 Intention, 31 Intentional fallacy, 3, 64n124, 69, 70, 72, 75, 75n12, 77, 80, 108 Intentional humanities, 61, 137, 175, 226, 228, 229, 231 Intentional science, 72, 106, 107, 109, 110, 112, 113, 124, 126 Intentions in academic writing, 115 as actionable, 16 active, 219 alternative, 33 authorial, 71, 75, 76, 79, 80 as building relationships, 32 Burke definition of, 133 Burke on in Pascal’s letter, 135 and change, 49 as curation, 204 and Derrida, 41 vs. desire, 15 and disaggregating performance, 55 and disciplinary prohibition, 3 discourse studies, 55 dismissal, 69 and durability as a concept, 26

as durable, 44 of electronic medical records, 170 and empiricism, 93 as enacted in text, 45 as ephemeral, 26 and expulsion from textual studies, 65 exteriorize, 15 final, 219 heterogeneity, 41 as heuristic, 17, 134 in humanities writing, 118 and incentives, 161, 184 insincere, 37 as instrument, 57 as interested truths, 45 justify action, 85 as language game, 52 as layered implications, 203 in meaning, 41 in metrics, 183 misplaced/misconceived, 43 motivate discursive production, 45 as naturalizing genre, 87 as operational strategy, 188 original, 41 overt in scholarship, 203 patient vs. physician, 158 in performative discourse, 37 physicality, 31 physician, 157 and postmodern argument, 84 and post-truth, 67 and prehospital care, 140 as proactive spaces, 203 professional, 157, 221

 Index 

programmatic, 219 reconsidered implications of, 55 referential, 32 requiring discourse, 52 resists definition, 31 and restoration in criticism, 84 revenue generating in healthcare, 164 and scientific practice, 124 and self-reflection, 2 as situated, 203 as situationally graphed, 55 as space making, 104 as speculative instrument, 58 student, 83, 84 subordination, 81 technological, 105 as tie between author and reader, 41 and trace, 44 and uncertainty, 26n1 as unobtainable, 81 Interpretation, 20, 22, 26n1, 29, 32–34, 39, 56, 64, 71–73, 76, 78, 79, 81, 136, 158, 188, 208, 233 Iterable, 41, 42, 44 utterance as, 41 J

Jenkins-Smith, Hank, 90, 90n65, 92, 92n73 K

Kahan, Daniel, 90, 90n65, 90n66, 92, 92n73 Khalidi, Muhammad Ali, 108, 109

241

Knapp, Steven, 71, 71n4 Krebs cycle, 7 Kress, Gunther, 53 L

Lakoff, George, 65, 65n128, 117 Language as intentional behavior, 39 as outside thought, 41 Latour, Bruno, 62, 63n119, 190, 190n29 Levinson, Stephen, 34, 36 Locution, 36 Logocentrism, 43 Los Angeles, 119–121, 120n53 Lyon, Arabella, 15, 26, 26n1, 26n2, 29–31, 54, 56, 63–65, 64n122 M

Margolis, Joseph, 71–74, 71n5, 72n6, 72n7, 73n8, 74n10, 96 Martin, J.R., 45–48, 51, 53, 54, 119n52, 134, 203, 204 Martin, James R., 208 McComiskey, Bruce, 66, 66n132 McIntyre, Lee, 65, 65n129, 65n130, 66, 66n131 McKenzie, Donald F., 64, 64n123, 95–97, 95n78, 96n79, 96n80, 97n81, 97n82 Meaning in analytics, 180 patient vs. physician, 158 in science, 125 Meaningful use, 17, 145n33, 146 Micropractices analytics as, 189

242 Index

Miller, Carolyn, 87, 87n54, 88, 88n55, 88n56 Mitochondria, viii, 6–9, 7n4, 13 Mitochondrial disease, 1, 6, 9n8, 23 Moati, Raoul, 38, 38n41, 38n42, 38n43, 41, 42n55, 42n56, 43, 43n57, 66, 66n133 Mukherjee, Siddhartha, 199, 199n4, 199n5 Muller, Jerry Z., 183, 183n15, 183n16, 185–187, 185n19, 186n21, 187n25 N

Nanotechnology, ix, 10, 60, 61, 90, 100–103, 103n6, 105, 118–123, 122n58, 123n62, 127, 129 Narrative, 14n22, 73, 73n9, 83, 110, 111, 159n64, 169n85, 169n86, 170n87, 208 collective, 30 EMR and excision from clinical inverview, 165 fragmentation in EHR, 169 patient, 164, 165, 167, 169, 170 patient and billing, 167 Naturalization, 94, 208 and de-naturalize, 94 Naturalizing intent in scholarship, 203 Neel, Jasper, 76, 77n20, 82, 82n42 O

Osler, William, 60

P

Pantelides, Kate, 53, 54 Paramedicine, 60, 137, 140, 149, 150, 202, 223, 224n1, 225, 226, 228 Pascal, Blaise, 17, 133–136, 135n4, 135n5, 135n6 Pellegrino, Edmund, 60 Perfect instruments, 112 Performance, 35–38, 43 Performative, 36–38, 40, 55 Personalized medicine, 61, 201 Petrusich, Amanda, 205, 206, 206n16, 206n17, 206n18, 206n19, 207n20, 208, 208n26 Pflugfelder, Ehren, 208 Polysemy, 33, 87 Positive discourse analysis, 47, 48 Post-genre, 94, 206 Post-intention, 72, 78 Post-truth, 65–67 Potsdam, NY, viii, 2, 10, 14, 21, 224 Practical application, 57 Practical knowledge, 57 Pre-hospital, vii, viii, 60, 143n25, 197, 198, 202, 223, 224, 228 Prescriptions unfilled, 129 Primary care physicians, 146, 151, 160 Process engineering, 145 Production, 56–57 Professional, vii, ix, 6, 22, 29, 35, 59, 60n110, 62, 65, 67, 71, 74, 76n18, 77, 85, 94, 118, 137, 157, 182n13, 186, 198n2, 202, 216, 221, 229 critic, 79

 Index 

Professional discourse, 22, 72, 94, 220, 222 Professional judgment, 186 Public input, 124 Q

Quill, Timothy, 201, 201n8, 201n9, 201n10, 201n11, 201n12, 201n13, 202n14 R

Rabinow, Paul, vii, viii, 10–12, 10n9, 11n10, 11n11, 11n12, 11n14, 12n15, 12n16, 12n17, 57, 58n108, 59, 59n109, 63, 70n2, 91, 91n69, 91n70, 104, 105, 105n12, 107n21, 112, 112n34, 112n35, 113, 119, 124–129, 125n65, 126n71, 127n74, 128n75, 129n78, 129n79, 129n80, 137, 189–191, 189n27, 189n28, 190n30, 190n31, 191n32, 191n33, 195, 196, 196n40 Readmissions, 145, 146, 147n35, 148n36, 149, 153–156, 153n41, 154n43, 154n44, 154n47, 155n48, 160, 185, 187, 187n23, 190 adverse events, 146 success of penalties, 154 Ribeiro, Branca Telles, 214–216 Richards, Ivor Armstrong, 57 Ricoeur, Paul, 78, 78n26, 78n27 Rules, 39, 43, 44, 56, 134, 174n1, 190, 211n33 Rybczynki, Witold, 124

243

S

Sanders, Lisa, 164, 166, 166n78 Sarkar, Shotra, 107, 108n23, 109, 125 Science of intentional change, 105 Scientific communication broken, 225 Searle, John, 21, 26n4, 34n28, 38n41, 39–46, 66 Semantic argument, 45 Siegel, Reva, 209, 209n28, 210, 210n29, 210n31, 210n32 Significance vs. meaning, 29, 67, 70, 73, 76, 79–82, 87–89, 91, 93, 97, 99, 156, 158, 161, 180, 191, 195, 220 Smalley, Richard, 102, 120 Social use, 38 Space and manipulation, 105 Speculative instrument, 57 Speech act, 34, 35, 38, 43, 44, 93 Sperber, Dan, 33, 34, 35n30 Student intent, 85 Student writing, 83 Synthetic biology, 61, 63n120, 105, 137 T

Terministic screens, 17, 134, 136, 171, 172 as misdirection, 135 Textual silences, 21, 22, 217, 218 Toombs, Kay, 156–161, 156n51, 156n52, 157n53, 157n54, 157n58, 158n59, 158n60, 158n61, 159n62, 159n63, 159n64, 164

244 Index

TRAP laws, 209, 210 Truth vs. meaning, 70 Two faces of discourse analysis, 47 U

Uncertainty, 2, 26n1, 198–200 Unintended consequences, 122, 144, 170n87 Urban design, 104, 112, 118–121, 130

Wilson, Deirdre, 33, 34, 35n30 Wimsatt, William K, 64, 64n124, 64n125, 64n126, 75–77, 75n12, 75n13, 75n14, 75n15, 75n16, 75n17, 76n18, 77n21, 77n22, 77n23, 80, 93–97, 97n82, 97n83 Wittgenstein, Ludwig, 31, 32, 111 Woodward, Gary, 26, 26n1, 27n5, 30, 31, 31n17, 59, 62 X

W

Wallace, David, 28n7 Weber, Max, 91n69, 107n21, 124–127, 125n66, 126n68, 126n70, 127n73, 130 Wilson, David Sloan, 105, 106, 109, 111, 113, 126

X-Files, 203 ‘X-Files’ fallacy, 45 Y

Yaffa, Joshua, 65, 65n127, 66 Yule, George, 32–34, 32n19, 32n20, 32n21, 33n25, 38n43